Guidelines For Maternity Care 2016

GUIDELINES FOR MATERNITY CARE IN SOUTH AFRICA
GUIGUIDGUI
ELIDELINDESELINESFOR
NESFORMATERNI
FORMATERNI
MATERNI
TYTCARE
YTCARE
Y CARE
IN ISOUTH
N ISOUTH
N SOUTH
AFRIAFRICAFRI
ACACA
GUIDELINES FOR
MATERNITY CARE
IN SOUTH AFRICA
A manual for clinics, community
health centres and district hospitals
Fourth Edition 2016
A long and healthy life for all South Africans

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GUIDELINES
GUIDELINES
GUIDELINESFOR
FOR
FOR
3 MATERNITY
3 MATERNITY
3 MATERNITY
CARE
CARE
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FORFORMATERNITY2016
2016
FORMATERNITY
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CARE
CARE
IN INSOUTH
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SOUTH
AFRICA
AFRICA
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GUIDELINES FOR MATERNITY CARE

IN SOUTH AFRICA
Fourth Edition 2016
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GUIDELINESFOR FOR
FOR
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ACKNOWLEDGEMENTS
FourthEdition
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2016
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The National Maternity Guidelines Committee at the Department of Health, Pretoria, has prepared this
document. This fourth edition of the guidelines is extensively updated, but follows the general format of the
successful previous editions. The contents are the result of broad and intensive discussions, feedback and
debate.
MEMBERS OF THE NATIONAL MATERNITY GUIDELINES COMMITTEE
Prof. E Buchmann Gauteng

R Van der Walt Gauteng
Dr J Geldenhuys Limpopo
E Moshabela Limpopo
D Mafura Free State
Dr M Schoon Free State
Dr D Mngomezulu Free State
V Mubaiwa KwaZulu-Natal
Dr Z Farina KwaZulu-Natal
Prof. J Moodley KwaZulu-Natal
Dr N Moran KwaZulu-Natal
P Phungula KwaZulu-Natal
M Lekhoathi Northern Cape
Dr J Van Soest Northern Cape
E Arends Western Cape
Dr G Gebhardt Western Cape
Dr S Ngcobo SANBS
Dr M Mdaka Eastern Cape
N Gaba Eastern Cape
C Modise North West
Dr M Mphatsoe North West
A Mafunisa National Department of Health
Dr N Khaole National Department of Health
P Robinson National Department of Health
G Wilkins Reducing Maternal Mortality through Strangthening Primary
Healthcare in South Africa Programme (RMCH) - editing
GUIDELINES
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TABLE OF CONTENTS
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ACRONYMS AND ABBREVIATIONS USED IN THE TEXT ................................................................................................................. 8
FOREWORD ........................................................................................................................................................................................ 10
CHAPTER 1: MATERNITY CARE IN SOUTH AFRICA....................................................................................................................... 12

MaTERNaL MORTaLiTY ................................................................................................................................................................. 12
SuMMaRY OF KEY RECOMMENDaTiONS FROM THE SaViNG MOTHERS REPORT 2011-2013 ............................................ 12
SaFE MOTHERHOOD iN SOuTH aFRiCa .................................................................................................................................... 13
a NaTiONaL STRaTEGY FOR MaTERNiTY CaRE ....................................................................................................................... 13
ObJECTiVE OF THE NaTiONaL GuiDELiNES.............................................................................................................................. 14
uSiNG THESE GuiDELiNES .......................................................................................................................................................... 14
CHAPTER 2: LEVELS OF CARE ........................................................................................................................................................ 17
DEFiNiNG LEVELS OF CaRE ........................................................................................................................................................ 17
CLiNiC ............................................................................................................................................................................................. 17
COMMuNiTY HEaLTH CENTRE .................................................................................................................................................... 17
DiSTRiCT HOSPiTaL ...................................................................................................................................................................... 18
REGiONaL HOSPiTaL .................................................................................................................................................................... 18
TERTiaRY HOSPiTaL ..................................................................................................................................................................... 19
EMERGENCY TRaNSPORT ........................................................................................................................................................... 19
CENTRaL HOSPiTaL ...................................................................................................................................................................... 19
CHAPTER 3: CLINICAL IN-PATIENT RECORD KEEPING: OBSTETRICS ...................................................................................... 21
PuRPOSE OF RECORD KEEPiNG STaNDaRDS ......................................................................................................................... 21
STaNDaRDS FOR iNPaTiENT RECORD KEEPiNG ...................................................................................................................... 21
ORGaNiSaTiON OF THE STaNDaRDS ......................................................................................................................................... 21
NOTES MaDE aT THE aNTENaTaL CLiNiC .................................................................................................................................. 22
aCuTE EVaLuaTiON (NOT FOR aDMiSSiON) ............................................................................................................................. 22
aDMiSSiON NOTES (aCuTE aDMiSSiON) ................................................................................................................................... 22
FOLLOw- uP NOTES ..................................................................................................................................................................... 23
HaNDOVER NOTES: TRaNSFER OF aCCOuNTabiLiTY ............................................................................................................ 23
iNTRaPaRTuM aND LabOuR waRD NOTES .............................................................................................................................. 23
REFERRaL NOTES uSiNG THE SbaR (SiTuaTiON-baCKGROuND-aSSESSMENT-RECOMMENDaTiONS) FORM ............ 23
DELiVERY NOTES .......................................................................................................................................................................... 23
SuRGERY aND iNVaSiVE PROCEDuRES NOTES ...................................................................................................................... 23
DiSCHaRGE NOTES ...................................................................................................................................................................... 24
abbREViaTiONS iN NOTES .......................................................................................................................................................... 24
CHAPTER 4: ANTENATAL CARE ...................................................................................................................................................... 29
PRiNCiPLES OF aNTENaTaL CaRE ............................................................................................................................................. 29
ObJECTiVES ................................................................................................................................................................................... 29
PRECONCEPTiON CaRE ............................................................................................................................................................... 29
RiSK FOR GENETiC DiSEaSE....................................................................................................................................................... 29
THE MATERNITY CASE RECORD ................................................................................................................................................. 29
RELaTiONSHiP wiTH PRiVaTE CaREGiVERS ............................................................................................................................ 30
THE FiRST aNTENaTaL ViSiT ....................................................................................................................................................... 30
MiD-uPPER aRM CiRCuMFERENCE............................................................................................................................................ 31
ESTiMaTiON OF GESTaTiONaL aGE ........................................................................................................................................... 31
ESSENTiaL SCREENiNG iNVESTiGaTiONS ................................................................................................................................ 31
FiNaL aSSESSMENT ...................................................................................................................................................................... 32
iNFORMaTiON FOR PREGNaNT wOMEN ................................................................................................................................... 32
SubSEQuENT aNTENaTaL ViSiTS ............................................................................................................................................... 33
CHAPTER 5: NORMAL LABOUR AND DELIVERY ........................................................................................................................... 40
SKiLLED aTTENDaNCE aT biRTH aND MOTHERS’ waiTiNG aREaS ....................................................................................... 40
DiaGNOSiS OF LabOuR ............................................................................................................................................................... 40
aDMiSSiON OF a wOMaN iN LabOuR ........................................................................................................................................ 40
GENERaL CaRE OF wOMEN iN LabOuR ................................................................................................................................... 40
ROuTiNE MONiTORiNG iN THE FiRST STaGE OF LabOuR ...................................................................................................... 41
MaNaGEMENT OF THE SECOND STaGE OF LabOuR .............................................................................................................. 42
MaNaGEMENT OF THE THiRD STaGE OF LabOuR................................................................................................................... 43
MaNaGEMENT OF THE FOuRTH STaGE OF LabOuR............................................................................................................... 43
abNORMaLiTiES OF THE FiRST STaGE OF LabOuR ................................................................................................................ 43
abNORMaLiTiES OF THE SECOND STaGE OF LabOuR ........................................................................................................... 45
VaCuuM EXTRaCTiON/VENTOuSE DELiVERY .......................................................................................................................... 45
FORCEPS DELiVERY ..................................................................................................................................................................... 46
CaESaREaN SECTiON .................................................................................................................................................................. 46
EMERGENCiES DuRiNG LabOuR................................................................................................................................................ 48
abNORMaLiTiES iN THE THiRD aND FOuRTH STaGES............................................................................................................ 49
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CHAPTER 6: BLEEDING IN EARLY PREGNANCY ........................................................................................................................... 59
MiSCaRRiaGE ................................................................................................................................................................................ 60
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uNSaFE MiSCaRRiaGES .............................................................................................................................................................. 61
POST-MiSCaRRiaGE/abORTiON FOLLOw-uP ........................................................................................................................... 61
MaNuaL VaCuuM aSPiRaTiON TECHNiQuE ............................................................................................................................. 62
ECTOPiC PREGNaNCY ................................................................................................................................................................. 63
CHAPTER 7: BLOOD TRANSFUSION ............................................................................................................................................... 66
REQuEST FOR bLOOD aND bLOOD PRODuCTS ...................................................................................................................... 66
ORDERiNG PRiORiTiES ................................................................................................................................................................ 66
GuiDELiNES ON THE MaNaGEMENT OF aCuTE MODERaTE/SEVERE TRaNSFuSiON RELaTED aDVERSE EVENTS ..... 67
CHAPTER 8: HYPERTENSIVE DISORDERS IN PREGNANCY ........................................................................................................ 69
DEFiNiTiONS .................................................................................................................................................................................. 69
CLaSSiFiCaTiON ............................................................................................................................................................................ 69
HOw TO TaKE bLOOD PRESSuRE iN PREGNaNCY.................................................................................................................. 70
wOMEN aT RiSK FOR THE DEVELOPMENT OF PRE-ECLaMPSia............................................................................................ 70
THE ROLE OF DiSTRiCT HOSPiTaLS iN MaNaGiNG HYPERTENSiVE DiSORDERS iN PREGNaNCY .................................. 70
aCTiONS TO TaKE iF THERE iS a RiSE iN bLOOD PRESSuRE FROM a PREViOuS ViSiT .................................................... 71
MEaSuRES TO PREVENT PRE-ECLaMPSia ............................................................................................................................... 71
HOw TO MaNaGE HYPERTENSiON iN PREGNaNCY ................................................................................................................ 71
MaNaGEMENT OF SEVERE PRE-ECLaMPSia/iMMiNENT ECLaMPSia iN a DiSTRiCT HOSPiTaL ........................................ 72
STEP-wiSE MaNaGEMENT OF ECLaMPSia ............................................................................................................................... 73
POSTPaRTuM aND POSTNaTaL CaRE ....................................................................................................................................... 73
CHOiCE OF DRuGS FOR POST-PaRTuM HYPERTENSiON....................................................................................................... 74
CHAPTER 9: PROBLEMS IN PREGNANCY ...................................................................................................................................... 77
iNTRauTERiNE GROwTH RESTRiCTiON .................................................................................................................................... 77
aNTEPaRTuM HaEMORRHaGE ................................................................................................................................................... 78
MuLTiPLE PREGNaNCY ................................................................................................................................................................ 81
bREECH PRESENTaTiON aND TRaNSVERSE LiE...................................................................................................................... 82
PRETERM LabOuR ........................................................................................................................................................................ 83
PRELabOuR RuPTuRE OF THE MEMbRaNES .......................................................................................................................... 84
CHORiOaMNiONiTiS ...................................................................................................................................................................... 85
PROLONGED PREGNaNCY .......................................................................................................................................................... 86
VaGiNaL biRTH aFTER PREViOuS CaESaREaN SECTiON (VbaC)......................................................................................... 87
RHESuS iNCOMPaTibiLiTY ........................................................................................................................................................... 88
POOR ObSTETRiC HiSTORY ........................................................................................................................................................ 89
CHAPTER 10: MANAGEMENT OF INTRA-UTERINE DEATHS, STILLBORN BABIES AND NEONATAL DEATHS ...................... 91
LEGaL DEFiNiTiONS ...................................................................................................................................................................... 91
iNTRauTERiNE DEaTH (iuD) ........................................................................................................................................................ 91
POSTNaTaL iNVESTiGaTiON OF STiLLbiRTHS aND NEONaTaL DEaTHS ............................................................................... 92
MaNaGEMENT OF a PaTiENT wiTH a PREViOuS STiLLbiRTH aFTER 24 wEEKS ................................................................. 92
MaNaGEMENT OF a STiLLbORN “bODY” (28 wEEKS GESTaTiONaL aGE aND MORE) ........................................................ 93
MaNaGEMENT OF a STiLL bORN “bODY” bELOw 28 wEEKS GESTaTiONaL aGE ................................................................ 93
MaNaGEMENT OF a NEONaTaL DEaTH ...................................................................................................................................... 93
CHAPTER 11: MEDICAL DISORDERS IN PREGNANCY .................................................................................................................. 95
aNaEMia ......................................................................................................................................................................................... 95
DiabETES MELLiTuS ..................................................................................................................................................................... 96
CaRDiaC DiSEaSE ........................................................................................................................................................................ 97
aSTHMa .......................................................................................................................................................................................... 99
THROMbOEMbOLiSM (VTE) ......................................................................................................................................................... 99
EPiLEPSY ........................................................................................................................................................................................ 99
CHAPTER 12: INFECTIONS IN PREGNANCY................................................................................................................................. 102
SEXuaLLY TRaNSMiTTED iNFECTiONS.................................................................................................................................... 102
GENiTaL uLCERS......................................................................................................................................................................... 102
uRiNaRY TRaCT iNFECTiON ...................................................................................................................................................... 103
aCuTE PYELONEPHRiTiS ........................................................................................................................................................... 103
MaLaRia........................................................................................................................................................................................ 104
CHAPTER 13: PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT) AND MANAGEMENT OF HIV POSITIVE
PREGNANT WOMEN ........................................................................................................................................................................ 108
PMTCT iN aNTENaTaL CaRE ...................................................................................................................................................... 108
HiV COuNSELLiNG aND TESTiNG ............................................................................................................................................. 108
aNTENaTaL MaNaGEMENT ........................................................................................................................................................ 108
iNiTiaTiON OF aNTiRETROViRaL PROPHYLaXiS OR TREaTMENT ....................................................................................... 108
HEPaTiTiS b CO-iNFECTiON ....................................................................................................................................................... 109
LabOuR aND DELiVERY ............................................................................................................................................................. 110
iNTRaPaRTuM MaNaGEMENT ................................................................................................................................................... 110
MaNaGEMENT OF LabOuR.........................................................................................................................................................111
POSTNaTaL CaRE ....................................................................................................................................................................... 113
STOPPiNG MaTERNaL HaaRT ................................................................................................................................................... 113
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wOMEN NEwLY DiaGNOSED HiV POSiTiVE DuRiNG bREaSTFEEDiNG .............................................................................. 114
TERMiNaTiON OF PREGNaNCY ................................................................................................................................................. 115
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iMPROViNG MaTERNaL HEaLTH aND PREVENTiNG MaTERNaL MORTaLiTY ..................................................................... 115
TubERCuLOSiS (Tb) iN PREGNaNCY ....................................................................................................................................... 118
OTHER OPPORTuNiSTiC iNFECTiONS (OiS) iN HiV POSiTiVE PREGNaNT wOMEN .......................................................... 118
CHAPTER 14: GUIDELINES FOR PERINATAL REVIEW MEETINGS (PNRM) AT FACILITIES..................................................... 123
CHAPTER 15: BASIC ULTRASOUND AT DISTRICT LEVEL .......................................................................................................... 128

DiSTRiCT LEVEL (LEVEL 1 SCaN) .............................................................................................................................................. 128
REQuESTS FOR DOPPLER OF THE uMbiLiCaL aRTERY ....................................................................................................... 128
SCREENiNG FOR CONGENiTaL aNOMaLiES ........................................................................................................................... 129
uLTRaSOuND DaTiNG POLiCY .................................................................................................................................................. 130
CHAPTER 16: RESPONDING TO A MATERNAL DEATH AT A HEALTH CARE FACILITY ........................................................... 133
iMMEDiaTELY ............................................................................................................................................................................... 133
wiTHiN 72 HOuRS ....................................................................................................................................................................... 133
wiTHiN ONE MONTH ................................................................................................................................................................... 133
wiTHiN THREE MONTHS............................................................................................................................................................. 133
CHAPTER 17: ROUTINE POSTNATAL CARE ................................................................................................................................. 135
POSTNaTaL CaRE aFTER NORMaL VaGiNaL DELiVERY........................................................................................................ 135
POSTNaTaL CaRE aFTER CaESaREaN DELiVERY ................................................................................................................. 136
abNORMaLiTiES OF THE PuERPERiuM ................................................................................................................................... 136
APPENDIX 1: ESSENTIAL EQUIPMENT, DRUGS AND TOOLS PER LEVEL OF CARE FOR
MATERNAL HEALTH SERVICES ..................................................................................................................................................... 139
APPENDIX 2: ANTENATAL CORTICOSTEROID THERAPY AT DISTRICT LEVEL FOR REDUCTION OF NEONATAL

MORBIDITY AND MORTALITY.........................................................................................................................................................140
TABLE OF FIGURES
Figure 3.1 SBAR Clinical Report ..........................................................................................................................................................

........................................................................................................................................................ 25 24
Figure 3.2: List of agreed abbreviations that can be used in clinical notes ..........................................................................................
........................................................................................ 2625
Figure 4.1: Antenatal card of a woman with certain (correct) dates .....................................................................................................
................................................................................................... 34 34
Figure
Figure 4.2:
4.2: Antenatal
Antenatal cardcard ofof a
a woman
woman with with uncertain
uncertain dates dates ................................................................................................................
.............................................................................................................. 35 35
Figure
Figure 4.3:
4.3: Clinic
Clinic checklist
checklist – – classifying
classifying (first)
(first) visit
visit ...............................................................................................................................
............................................................................................................................. 36 36
Figure
Figure 4.4:
4.4: Check
Check list
list of
of risk
risk factors
factors requiring
requiring referral
referral or or hospital
hospital delivery
delivery ...........................................................................................
......................................................................................... 3737
Figure 4.5: Clinic checklist: Booking and follow-up of HIV negative patient ......................................................................................... 38
Figure 4.5: Clinic checklist: Booking and follow-up of HIV negative patient ....................................................................................... 38
Figure 5.1: Oxytocin for induction or augmentation of labour ............................................................................................................... 44
Figure 5.2:
Figure 5.1: Common
Oxytocin for inductionfor
indications orCTG
augmentation
monitoringofinlabour labour.............................................................................................................
............................................................................................................4545
Figure 5.3:
Figure 5.2: B-Lynch
Commonbrace indications
suturefor CTG monitoring in labour .......................................................................................................... 46
......................................................................................................................................................... 51
Figure 5.4:
Figure 5.3: Postpartum
B-Lynch brace suture .......................................................................................................................................................
haemorrhage (PPH) after vaginal birth ...........................................................................................................52 53
Figure 5.5:
Figure 5.4: Bleeding
Postpartum haemorrhage
at caesarean (PPH)
delivery after vaginal birth ......................................................................................................... 54
.......................................................................................................................................... 54
Figure 5.6:
5.5: Bleeding after
at caesarean
caesarean delivery
delivery ........................................................................................................................................
......................................................................................................................................55 55
5.6: Problems
Figure 5.7: Bleeding after caesarean
requiring referraldelivery
from chc ....................................................................................................................................
to hospital during labour or postpartum ...................................................................56 56
Figure 5.8:
5.7: Completed partogram.........................................................................................................................................................
Problems requiring referral from chc to hospital during labour or postpartum ................................................................. 57 57
Figure 6.1:
5.8: Problems
Completedassociated with vaginal bleeding........................................................................................................................58
partogram....................................................................................................................................................... 59
Figure
Figure 8.1:
6.1: Fetal movement
Problems chart.........................................................................................................................................................
associated with vaginal bleeding...................................................................................................................... 60 75
Figure
Figure 9.1:
8.1: Distinction
Fetal movement between abruptio placentae and placenta praevia ...........................................................................................76
chart....................................................................................................................................................... 78
Figure
Figure 9.2:
9.1: Algorithm
Distinctionfor the diagnosis
between abruptio and management
placentae of Antepartum
and placenta praeviaHaemorrhage (APH) ...........................................................79
......................................................................................... 80
Figure 9.3: Algorithm for the management of prelabour rupture of the membranes ............................................................................ 85
Figure 9.2: Algorithm for the diagnosis and management of Antepartum Haemorrhage (APH) ......................................................... 81
Figure 11.1: Risk factors for gestational diabetes................................................................................................................................. 96
Figure 9.3: Algorithm for the management of prelabour rupture of the membranes .......................................................................... 86
Figure 12.1: Assessing malerial severity ............................................................................................................................................ 105
Figure 12.2:
Figure 11.1: Risk factorsoral
Outpatient for desensitisation
gestational diabetes protocol ...............................................................................................................................
for patients with penicillan allergy ................................................................... 106 97
Figure 12.1: Assessing
Figure 13.1: HIV testingmalerial severity ..........................................................................................................................................
and counselling (from National PMTCT Guidelines)....................................................................................106 109
Figure 13.2:
Figure 12.2: PMTCT
Outpatient oral desensitisation
Algorithm protocol for patients with penicillan allergy ................................................................. 107
............................................................................................................................................................111
13.1: Viral
Figure 13.3: HIV testing
Load inand counselling
pregnant women (from
not National
yet on HAART PMTCT orGuidelines)
newly diagnosed ...................................................................................
.......................................................................... 110
112
Figure 13.4:
13.2: Infant
PMTCT Algorithm and
prophylaxis ...........................................................................................................................................................112
PCR testing during the first few months of life ........................................................................... 113
Figure 15.1:
13.3: Graph
Viral Loadshowing percentage
in pregnant women risknot
foryetDown Sydrome
on HAART orinnewly
live births
diagnosed with increasing age ................................................... 113
......................................................................... 129
Figure 17.1:
13.4: Management
Infant prophylaxis of puerperal
and PCRsepsis testing ...................................................................................................................................
during the first few months of life .......................................................................... 114 138
Figure 13.5: Infant prophylaxis and PCR testing for infants of known HIV positive pregnant women.................................................118
FigureFigures
Note: 13.6: Management
are labeledofaccording
infants born to tothemothers
chapters withnotTB.chronoligical.
........................................................................................................... 121
Figure 13.7. Screen-and-treat algorithm for ART-naive adult patients with a CD4+ T-lymphocyte count.......................................... 122
Figure 15.1: Graph showing percentage risk for Down Sydrome in live births with increasing age ................................................. 130
Figure 17.1: Management of puerperal sepsis ................................................................................................................................. 139
Note: Figures are labeled according to the chapters not chronoligical.
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ACRONYMS AND ABBREVIATIONS USED IN THE TEXT

FourthEdition
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AC Abdominal Circumference
AIDS Acquired Immunodeficiency Syndrome
APH Antepartum Haemorrhage
ARDS Adult Respiratory Distress Syndrome
AVPU Alert, verbal questions, pain, unresponsive
AZT Zidovudine
BMI Body Mass Index
BP Blood Pressure
BPD Bi-Parietal Diameter
BRB Blood on Returnable Basis
Ca Cancer
CD4 T-helper cells-a Unit Measure of the Immune System
CEO Chief Executive Officer
CHC Community Health Centre
CPAP Continuous Positive Airway Pressure
CPD Cephalo-Pelvic Disproportion
CD Caesarean Delivery
CPR Cardio Pulmonary Resuscitation
CRL Crown Rump Length
CT SCAN Computerised Tomography
CTG Cardiotocograph
CVP Central Venous Pressure
CXR Chest X-Ray
D&C Dilatation and Curettage
DCST District Clinical Specialist Teams
DIC Disseminated Intravascular Coagulation
DVT Deep Vein Thrombosis
ECG Electro Cardiogram
ECV External Cephalic Version
EDD Expected Date of Delivery
EFW Estimated Foetal Weight
EMS Emergency Medical Services
EOST Emergency Obstetric Simulation Training
EPI Expanded Programme on Immunisation
ESMOE Essential Steps in the Management of Obstetric Emergencies
FBC Full Blood Count
GTT Glucose Tolerance Test
HAART Highly Active Antiretroviral Treatment
HB Haemoglobin
HC Head Circumference
HCG Human Chorionic Gonadotrophin
HELLP Syndrome of haemolysis, elevated liver enzymes and low platelets
HOD Head of Department
HPCSA Health Professions Council of South Africa
ICU Intensive Care Unit
ID Infectious Diseases
IM Intra Muscular
INR International Normalized Ratio
IPT Isoniazid Preventative Therapy
IRIS Immune Reconstitution Inflammatory Syndrome
IUCD
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Intrauterine Contraceptive Device
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IUD Intrauterine Death

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IUGR Intrauterine Growth Restriction
IV Intravenous
IVI Intravenous Infusion
LMIC Low and Middle Income Countries
LP Lumbar Puncture
MC&S Microscopy, Culture and Sensitivity
MCR Maternity Case Record
MCV Mean Cell Volume
MCWH Maternal, Child and Women’s Health
MDNF Maternal Death Notification Form
MOU Midwife Obstetric Unit
MRI Magnetic Resonance Imaging
MSL Meconium Staining of the Liquor
MUAC Mid Upper-Arm Circumference
MVA Manual Vacuum Aspiration
NCCEMD National Committee for the Confidential Enquiries into Maternal Deaths
Neb Nebulisation
NGO Non-Governmental Organisation
NIBP Non-Invasive Blood Pressure
NPO Nil Per Os
NSAIDs Non-Steroidal Anti-Inflammatory Drugs
OI Opportunistic Infections
PCV Packed Cell Volume
PET Pre-Eclampsia
PID Pelvic Inflammatory Disease
PMTCT Prevention of Mother to Child Transmission
PNRM Perinatal Review Meeting
PO By Mouth
PP Parietal-Parietal
PPIP Perinatal Problem Identification Programme
PTT Partial Thromboplastin Time
Rh Rhesus Factor
RPR Rapid Plasma Reagin
RTHB Road To Health Booklet
SBAR Situation-Background-Assessment-Recommendation
SC Sub Cutaneous
SFH Symphysis-Fundal Height
STIs Sexually Transmitted Infections
TACO Transfusion Associated Circulatory Overload
TB Tuberculosis
TRALI Transfusion Related Acute Lung Injury
TST Tuberculin Skin Test
TT Tetanus Toxoid
TTO To Take Out (Drugs)
UTI Urinary Tract Infection
VBAC Vaginal Birth after Caesarean Section
VL Viral Load
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The Maternity Guidelines for Clinics and District hospitals

(Edition 2007) has been revised and new chapters such
as the use of blood and blood transfusion products,
early warning observation charts and professionalism in
health care have been added to give additional emphasis
to patient safety. The team that reviewed and upgraded
the guidelines are experts from all nine provinces, so this
edition should be regarded as National Guidelines, but
should be developed into clinical protocols at provincial
and institutional level, where necessary. I would like the
provincial obstetrician/gynaecologist as well as the District
Clinical Specialist Teams to ensure that these guidelines
and the necessary clinical protocols are available and
implemented in each facility at which deliveries are
conducted.
The national Department of Health will support wide

distribution, training in the guidelines as well as monitor
their use. In addition, it is imperative that medical and
nursing schools in the country use the maternity care
guidelines in their training programmes. The guidelines
contain the basic minimum that needs to be known by all
professional nurses and doctors. Their use will lower high
maternal and perinatal morbidity and mortality rates and
improve the quality of care for women, their babies and
The national Department of Health has identified maternal their families.
health care as a priority area requiring urgent action
in South Africa. This is in line with the target to achieve Finally, I wish to thank all the experts for their time and
the Millennium Development Goals (MDGs) as well as effort put into making this revision essential reading for
the targets set in our National Development Plan (NDP). those caring for pregnant women during the antenatal
To this end, we have supported the implementation of period, childbirth and the puerperium.
recommendations arising from the triennial Saving Mothers
Reports that have been produced by the Ministerially
appointed National Committee on Confidential Enquiries
into Maternal Deaths (NCCEMD).
The NCCEMD has recommended regular updating and

strengthening of guidelines on the clinical management
of the common causes of maternal deaths in South
Africa. Guidelines have to be updated on a regular basis
because of advances in medicine, development of new Dr A Motsoaledi, MP
pharmaceutical agents and the publication of results of Minister of Health
recent evidence-based clinical trials. Date:
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Chapter 1
MATERNITY CARE IN SOUTH AFRICA
Purpose of this chapter
This chapter provides an overview of the current situation and data on martenal care in
South Africa
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There is a continuing global commitment to reduce the unacceptably high maternal death rates in low to middle-income
countries (LMIC). Progress towards this goal in South Africa demands national coordination and cooperation with the
major role players in provision of health services, addressing causes of maternal and perinatal deaths and in making
available clinical management protocols to ensure that high quality health services are rendered.
Maternity care is an integral component of primary health care and a free health service for pregnant women. Within
South Africa, the Maternal and Child Health programme is located in general development policies, which are focused
on meeting the basic needs of rural and urban communities, maximising human resources potential, enlarging the
economy and spreading its benefits to all South Africans. To comply with these principles, the then Minister of Health
announced free health care services for pregnant women and children under the age of six years in July 1994.
MATERNAL MORTALITY
Maternal mortality is defined as the death of a woman while pregnant or within 42 days after delivery or after termination
of the pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the
pregnancy or its management, but not from accidental or incidental causes. Maternal deaths may be divided into:
• direct obstetric deaths - resulting from obstetric complications of pregnancy, labour or the puerperium, from
interventions, omissions, incorrect treatment or from a chain of events resulting from any of these
• indirect obstetric deaths - resulting from a previously existing disease that was aggravated by the physiological
effects of pregnancy
The definition implies and includes the following :

• irrespective of anatomical site(intrauterine,advanced extra-uterinepregnacy,ectopic pregnacy-
tubal,corneal,fimbrial,corneal and cervical sites)
• any gestational age (early pregnancy-miscarriage,sepsis,surgical complications,bleeding)
• labour(prolongedlabour from spontaneous and inducedlabour;elective and emergency CS)
• up to 42 days following delivery (any clinical condition including trophoblastic infections,sepsis,suicide, MVA,
etc.)
• irrespective of clinical diagnosis or medical discipline/area where the patient was admitted and includes
infections such as TB, bacterial pneumonias,meningitis and medical and surgical conditions such as
cardiac ,liver diseases and all malignancies including trophoblastic disorders (molar pregnancies and
choriocarcinoma) trauma and sucides
Data from the 2010 to 2013 South African Confidential Enquiries into Maternal Deaths Report suggest that the main
causes of maternal deaths are related to challenges of the healthcare system, failure to use health care facilities,
inadequacy of services and substandard care related to knowledge and skill of the health care providers.
According to the national Department of Health’s annual performance plan 2013/2014 report, the maternal mortality ratio
is 310 per 100 000 live births. However, the institutional maternal mortality ratio was 140.81 per 100 000 live births in the
year 2014 according to the Saving Mothers 2014 Annual Report of the National Committee on Confidential Enquiries
into Maternal Deaths (NCCEMD) in South Africa.
SUMMARY OF KEY RECOMMENDATIONS FROM THE SAVING MOTHERS REPORT 2008 -2010
RECOMMENDATIONS
The 2010-2013 report has clearly identified three conditions that contribute to the majority of preventable maternal
deaths, namely non-pregnancy related infections, obstetric haemorrhage and complications of hypertension in
pregnancy. These conditions comprise 66.7 per cent of the possibly and probably preventable maternal deaths. The
three conditions have many common preventable factors that are mostly related to the knowledge and skills of the health
care providers and the challenges within the healthcare system. The committee has summarised its recommendations
into five key points namely:
• HIV
• Haemorrhage
The 5 H’s • Hypertension
• Health worker training and
• Health system strengthening
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Promote the “know your status” and “plan your pregnancy” messages in communities and in the health sector; and ensure non-judgemental
approaches.
Ensure every maternity health facility is able to screen for HIV infection and perform early initiation of HAART therapy; and to recognise and treat
co-infections, especially respiratory infections.
Haemorrhage
Promote preventive interventions: community education, prevent prolonged labour, prevent anaemia; use of safe methods for induction of labour
and practice active management of the third stage of labour
Severe obstetric haemorrhage must have the status of a ‘major alert’ requiring a team approach; with immediate attention to diagnosis of the
cause of haemorrhage, resuscitation and stepwise approach to arresting the haemorrhage.
Hypertension
All maternity facilities must provide calcium supplementation to all women throughout their antenatal care and ensure the detection, early referral
and timely delivery of women with hypertension in pregnancy.
Severe hypertension, imminent eclampsia, eclampsia and HELLP syndrome must be recognised as life threatening conditions (Major Alerts)
requiring urgent attention. All maternity facilities must be able to administer magnesium sulphate to prevent convulsions, administer rapid acting
agents to lower severely raised blood pressure , provide close monitoring prior to and following delivery and manage fluid balance safely.
Promotion of Family Planning Services in the population at large (women, their partners, families and communities).
Health worker training

Train all health care workers involved in maternity care in the ESMOE-EOST programme and obstetric anaesthetic module.
Train all health care workers who deal with pregnant women in HIV advice, counselling, testing and support initiation of HAART, monitoring of
HAART and the recognition, assessment, diagnosis and treatment of severe respiratory infections.
Health systems strengthening
Ensure 24-hour access to functioning emergency obstetric care (both basic and comprehensive).
Ensure accessible and appropriate contraceptive services for all women which are integrated into all levels of health care and which must be
available on site for post-miscarriage and postpartum women.
SAFE MOTHERHOOD IN SOUTH AFRICA
The following are considered to be the ‘pillars’ of safe motherhood (based on the World Health Organization’s Safe
Motherhood Initiative):
1 Choice on contraception - to ensure that individuals and couples have the information and services to plan the timing, number and
spacing of pregnancies.
2 Basic antenatal care - the identification of risk factors and early diagnosis of pregnancy complications and appropriate management,
and health education.
3 Clean and safe delivery - to ensure that all health workers have the knowledge, skills and equipment to perform clean and safe
delivery and provide postpartum care to mother and baby.
4 Basic and Comprehensive emergency obstetric care (Essential Obstetric Care) - to ensure that essential care for high risk
pregnancies and complications is made available to all women who need it.
5 Choice on termination of pregnancy - to provide women who have unwanted pregnancies with a legal, safe and acceptable choice.
A NATIONAL STRATEGY FOR MATERNITY CARE
COMMUNITY PARTICIPATION
Women, families and communities must be empowered to contribute actively to improving maternal, perinatal and family
health. Conditions that adversely affect the outcome of pregnancy, such as sexually transmitted disease, unwanted
pregnancies and lack of transportation should be addressed within the communities involved. Ward-based outreach
teams as part of primary healthcare re-engineering will play an important role at community level.
A SUPPORTIVE LEGAL FRAMEWORK

Legislation and policies must be in place to support the national strategy in terms of free care, termination of pregnancy
services and protection of women. Politicians should publicly commit themselves to support improvements in healthcare
for pregnant women.
ADAPTATION TO LOCAL REALITIES

Some of the underlying causes of maternal and perinatal mortality, such as poverty, illiteracy and other national priorities,
must be taken into account in the consideration of inadequacies in the health service or the utilisation thereof by
pregnant women.
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Health workers administering care to pregnant women must demonstrate respect and a genuine interest in their clients,
and avoid an arrogant, rude or judgmental attitude. This applies even in the context of a poor working environment or
perceived unsafe practices of certain pregnant women.
IMPROVEMENT IN THE STATUS OF WOMEN

Active efforts must be made to improve the status of women in society, especially in education, reproductive choice,
employment and the prevention of abuse.
PROVISION OF SKILLED MIDWIFERY AND OBSTETRIC SERVICES

The three levels of the district healthcare pyramid (family and community, health centre, and district hospital) must
function in an efficient and cost-effective manner. Midwives and doctors are the best equipped to provide technologically
appropriate care to women during their reproductive lives. To prevent maternal deaths, all hospitals must offer caesarean
section and blood transfusion facilities. The practice of home deliveries, whether by professional or lay midwives, is not
encouraged.
CLINICAL GUIDELINES
The development of management guidelines for normal and high-risk pregnancies will provide a framework for a high
standard of maternity care.
REGIONALISED CARE AND REFERRAL SYSTEMS

The district is the basic unit of a healthcare region, served by a district hospital and a number of health centres. A well-
coordinated referral system, with access to transport and facilities, is essential for the provision of optimal care to all
pregnant women in the district.
MANAGEMENT CAPACITY
Poor management has been identified as a major weakness of health services in LMIC. Proper financial planning and
optimal management of staff and resources are keystones to a fully functional district or provincial health system.
CONTINUING AUDIT OF SERVICES

It is essential to review and audit services and practices in districts and provinces, to improve current services and
to develop new services where necessary. Medical and nursing audit meetings should be held at all levels of the
healthcare system.
RESEARCH
Important areas for research include evaluation of the impact of community involvement as a strategy for improving
maternal and neonatal health, operation and evaluation of reorganised antenatal care, and cost effectiveness studies
of various interventions.
OBJECTIVE OF THE NATIONAL GUIDELINES
These guidelines have been prepared by the Sub directorate: Maternal Health for the guidance of health workers
(doctors and midwives) providing obstetric, surgical and anaesthetic services for pregnant women in district clinics,
health centres and district hospitals.
In the absence of a functioning system of primary healthcare and without guidance for clinical management and referral,
pregnancy related deaths and ill health could be expected to continue at unacceptably high rates.
USING THESE GUIDELINES
FORMAT AND CONTENT

These guidelines are intended for use in clinics, community health centres and district hospitals where specialist services
are not normally available. The guidelines deal mainly with the diagnosis and especially the management of common
and serious pregnancy problems. The assumption is made that the reader has a basic knowledge and understanding
about the care of pregnant women. With a few exceptions (e.g. pre-eclampsia), there is no mention of aetiology and
pathogenesis of the conditions described.
The emphasis is on the practical identification and correct management of problems, including referral to higher
levels of care. The approach is unashamedly dry, and reduced to point format, so that a management plan can be
quickly assimilated and enacted. For certain clinical problems, algorithms (flow diagrams) have been prepared.
The guidelines are based on the best available evidence from published research, modified where necessary to suit
local conditions. References are not given, but are available from the authors on request. Specifics of management and
drug dosing are not cast in stone, and can be modified according to the experience and new evidence.
Each patient is an individual and may not necessarily be served best by the suggested guidelines. The guidelines would
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be used most effectively if individual hospitals and community health centres drew up their own protocols based on the
contents, adjusted to their own particular circumstances.
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Detailed guidelines on the following have been excluded from these guidelines:
• the role of community based resources - this includes community health workers, doulas (birth supporters),
traditional birth attendants and support groups
• technical descriptions of procedures - surgical techniques, ultrasound, amniocentesis, etc. cannot be learned
from a book. Emergency procedures such as breech delivery are however described
• neonatal care - only immediate care of the new-born is described
COPYRIGHT
Parts of the guidelines may be copied and circulated in hospitals, community health centres and clinics, but should be
acknowledged as part of the National Guidelines for Maternity Care in South Africa. The content is the property of the
Department of Health and may not be reproduced or rewritten for profit.
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Chapter 2
LEVELS OF CARE
This chapter describes the different levels of care in the South African health system and
explains the reasons behind the need for various levels.
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The definitions of levels of care have been modified, with minor adjustments, from the Department of Health’s Maternal,
Child and Women’s Health policy proposal, published in regulation 655 (2012).
The classification of hospitals is based on the level of functioning and includes the type of health professional that can
be employed at a facility, bed occupancy and the medical disciplines catered for at each level of care. The levels of care
are not location driven.
DEFINING LEVELS OF CARE
Different levels of healthcare are required for the efficient functioning of the health service. Most medical conditions do
not need the facilities of large hospitals. For cost-effective health management, clinics and hospitals should share the
load of patient care, whereby clinics manage common and low risk problems and hospitals the more difficult clinical
entities. It is essential to have a referral system in place with clear protocols of management, referral patterns, transport
and responsibilities of the various categories of health professionals.
Approximately 60-70 per cent of all women who use the government facilities will require the services of a hospital at
some stage during their pregnancies. About 15 per cent of women will require the services of a specialist obstetrician at
a regional or tertiary hospital.
The terms clinic, community health centre and district, regional, tertiary and central hospitals, will be used in these
guidelines and follow the definitions given below. Neonatal care staffing and facilities are not included.
Comprehensive lists of equipment, drugs and supplies appears at the end of this chapter. These lists may assist
managers of maternity care services to ensure that their facilities are adequately equipped.
CLINIC
This health facility normally functions only on weekdays during working hours. Antenatal care is one of a number of
activities in the clinic, the others being chronic diseases, child health, family planning, etc.
Functions
• antenatal care for low and intermediate risk women, including point of care blood and urine testing.
• postnatal follow-up visits, including the provision of contraceptive services
• referral of patients identified with risk factors for pregnancy complications to appropriate health facilities
(according to referral patterns)
• the immediate management of obstetric and neonatal emergencies
Staffing
Professional nurses, enrolled nurses, nursing assistants, community health workers and a visiting medical officer.
Facilities
• all the necessities to run an antenatal clinic
• equipment and drugs for obstetric emergencies (oxygen, ringer’s lactate solution, magnesium sulphate, nifedip-
ine tablets, salbutomol)
• sterile delivery packs for unscheduled deliveries
• reliable transport service for emergency transfer to an appropriate facility
• an effective communication system (radio or telephone)
• contraceptive services including insertion of IUCD’s and Implants
COMMUNITY HEALTH CENTRE
This is a 24-hour comprehensive health service with an obstetric unit run by midwives. Where it stands alone as a
maternity service, it might be called a midwife obstetric unit (MOU). More often, the maternity section will run alongside
other services such as emergency care, minor ailments, chronic diseases, and promotive services.
Functions
• low-to intermediate-risk antenatal care
• basic emergency obstetric care signal functions: magnesium sulphate, intravenous antibiotics, oxytocics,
vacuum delivery, removal of retained placenta, manual vacuum aspiration, neonatal resuscitation
• 24-hour labour and delivery service for low risk women
• comprehensive contraceptive care
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• referral of problems to hospital
• management of emergencies
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Advanced midwives, midwives, enrolled nurses, nursing assistants, community health workers, visiting or resident
dietician and a visiting or resident medical officer.
Facilities
• all the necessities to run an antenatal clinic
• all equipment to run a low risk labour ward
• hand-held doppler instrument for foetal heart auscultation
• an effective communication system (radio or telephone)
• reliable 24-hour transport service for emergency transfer to hospital
DISTRICT HOSPITAL
The package of services provided at district hospitals includes trauma and emergency care, in-patient and out-patient
visits; paediatric and obstetric care. These hospitals may employ specialist family physicians, obstetrician/gynaecologists
and paediatricians.
Functions
• antenatal care for high-risk women
• antenatal ultrasound service
• treatment of pregnancy problems, including admission to hospital
• comprehensive emergency obstetric care signal functions: magnesium sulphate, intravenous antibiotics,
oxytocics, vacuum delivery, removal of retained placenta, manual vacuum aspiration, neonatal resuscitation,
caesarean delivery and blood transfusion
• 24-hour labour and delivery service including caesarean delivery
• regional and general anaesthesia
• essential special investigations
• postnatal care and postoperative care
• contraceptive services including postpartum and elective tubal ligation
• referral centre for clinics and community health centres in the district
• supervision of clinics and community health centres in the district
• referral of complicated problems to regional or tertiary hospitals
• counselling and support services
• genetic screening and counselling services
Staffing
Advanced midwives, midwives, enrolled nurses, nursing assistants, social workers, dietician, full time medical officers
and visiting specialist obstetricians.
Facilities
• all the necessities to run an antenatal clinic including an ultrasound scanner
• all equipment to run a high-risk labour ward including a vacuum extractor, cardiotocograph (CTG) machines,
pulse oximeters and intravenous fluid infusion pumps
• a 24 hour laboratory service
• anthropometric equipment
• emergency blood
• equipment and drugs for obstetric emergencies including a fully equipped resuscitation trolley and defibrillator
• fully equipped operating theatre
• x-ray facilities
• reliable transport service for emergency transfer to regional or tertiary hospitals
• a mothers’ waiting area in rural areas with poor transport infrastructure
REGIONAL HOSPITAL
Hospitals at this level render services at a general specialist level, receive referrals from district hospitals, and they
serve as a platform for training and research. They may also provide some district services within the local sub-district.
Experienced specialists lead the teams and the medical disciplines include general surgery, orthopaedics, general
medicine, paediatrics, obstetrics and gynaecology, family medicine, radiology and anaesthetics.
A regional hospital is the base hospital for a health region that includes a number of districts. Regional hospitals frequently
offer the functions of district hospitals and are the base specialist health facility for clinics and community health centres
in their defined geographical area.
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• all district hospital functions including a blood bank
• management of severely ill pregnant women
• specialist supervision of the care of pregnant women
• prenatal diagnosis, e.g. genetic amniocentesis
• multidisciplinary care - other specialities, dietetics, physiotherapy, etc.
• referral centre for district hospitals and, if appropriate, clinics in the region
• supervision and support for district hospitals and clinics
Staffing
Advanced midwives, midwives, enrolled nurses, nursing assistants, dietician, full time medical officers and full time
specialist obstetricians.
Facilities
• all the facilities required in a district hospital
• high-care area providing short-term assisted ventilation
TERTIARY HOSPITAL
These hospitals render specialist and sub-specialist care to a number of regional hospitals and serve as a platform
for training of health care workers and research. They may also render some regional services. They may be called a
central (or tertiary) hospital.
Functions
• all regional hospital functions
• specialist combined clinics, e.g. cardiac and diabetic pregnancy clinics
• advanced prenatal diagnosis such as chorion villus sampling and cordocentesis
• management of extremely ill or difficult obstetric patients
• supervision and support for district and regional hospitals
• responsibility for policy and protocols in the regions served
Staffing
Advanced midwives, midwives, enrolled nurses, nursing assistants, full time medical officers and full time specialist
obstetricians, including sub-specialty skills.
Facilities
• all the facilities required in level one district and level two regional hospitals
• specialised equipment for the management of very ill or difficult obstetric patients
EMERGENCY TRANSPORT
Appropriately staffed and equipped dedicated obstetric ambulances are to be available 24 hours a day in all health
districts, to move women with emergencies from one health facility to another, or from their homes to a health facility.
Appropriate communications means, whether radio or telephone, must be in place so that ambulances can be called
to transport such women as rapidly as possible.
Requirements for a dedicated obstetric ambulance

• a midwife or qualified paramedic to accompany the patient in the vehicle
• all standard equipment for an ambulance, with essential materials for the care of a mother and new-born baby,
including a delivery kit
CENTRAL HOSPITAL
These hospitals render a very highly specialised tertiary and quaternary services on a national basis and provide a
platform of training of healthcare workers for high cost and low volume services.
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Chapter 3
CLINICAL IN-PATIENT RECORD KEEPING: OBSTETRICS
This chapter outlines the standards for the clinical structure and content of patient records.
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The rising demands on healthcare systems to deliver quality patient care as well as the constant increase in medico-
legal cases in maternity demand good quality of note keeping. This document describes standards for the structure and
content of a doctor’s obstetric patient records, covering the SBAR (situation-background-assessment-recommendation)
referral letter, antenatal clinic notes, inpatient notes (acute admission), in-patient notes (follow up notes), handover
communications and discharge summaries.
An important component of quality assurance is audits of clinical notes in patient records, as based on these standards.
Audit tools can be used to assess notes and partograms.
The standards consist of a list of clinical record headings and a description of the information that should be recorded
under each heading.
PURPOSE OF RECORD KEEPING STANDARDS
• to instil good practice in record keeping

• to present a historical record of clinical events to account for all care given to individual women
• to ensure that all clinical records are complete and accurate with regards to the information they contain
• to ensure that legal requirements are met in record keeping practices
• to ensure that all staff are made aware of their record keeping responsibilities
• to ensure that notes of doctors-in-training (undergraduate and interns) conform to the minimum standards and
are supervised by an appropriate clinician (medical officer or above)
STANDARDS FOR INPATIENT RECORD KEEPING
• record keeping in all clinical areas will be subject to monitoring

• all writing in clinical records must be legible
• all entries must be made in black (ball pen or black ink)
• all entries must be dated and timed (using the 24 hour clock)
• all entries must be signed; when the practitioner is writing in the patient’s record for the first time in any episode
of care they will also print their name and designation under their signature. Alternately, a name stamp can be
used
• mistakes must be crossed through with a single line, signed, dated and timed. Correction fluid may not be used.
Any sheets containing errors must not be removed from the clinical record
• the record will only include standard and accepted clinical abbreviations (see list of abbreviations in figure ,
page)
• all notes should be identified with a patient identity label or name and folder number
• the physical place where the patient was examined (e.g. labour ward, casualty unit, outpatient department, etc.)
should be indicated
Additional requirements
• These standards are for all medical personnel (medical students, interns, community service medical officers,
medical officers, registrars, professional nurses and specialists) involved in maternity care.
• Where clinical notes are made by students it should be countersigned by an HPCSA registered doctor; when
notes are made by an intern it should either be counter-signed by an HPCSA registered doctor or the name of
the HPCSA registered doctor responsible for that intern’s supervision at that time must be written in the notes.
• Try to make all entries as soon as the clinical event has taken place. When this is not possible, the record
should be dated and timed at the time of writing, with the date and time of the events being recorded stated in
the notes.
• The content of telephone communications (relevant to clinical care) should be recorded in the notes.
• The clinical notes should contain clinically relevant information only and should not include clinically irrelevant
information such as complaints, judgments of a personal nature, perceived undesirable attitudes of the patient
or alleged negligence or malpractice accusations.
• Results of special investigations must be noted as soon as it becomes available.
• Any known allergies must be noted (or the absence of any allergies).
• The initial (admission) notes for any admission episode should be complete; thereafter follow up notes are
sufficient.
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ORGANISATION OF THE STANDARDS

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The standards are organised in a series of sections with the full set of record headings identifying where they are used.
1 Antenatal care: outpatient notes made at each consecutive antenatal clinic visit after the initial booking.
Acute admission: the clinical information recorded in the hospital admission record on admission to hospital for antenatal/postnatal
2
problems or when in labour.
3 Follow-up notes: made after admission for acute antenatal or postnatal problem.
Handover notes: handover of patient care from one professional or team to another, including doctor-to-doctor or team-to-team
4
handover in hospital at night and over weekends.
5 Intrapartum notes: clinical notes made to complement the labour progress on the partogram.
6 Surgery notes: notes from surgery or instrumental delivery notes.
7 Discharge notes: the clinical information recorded in the discharge record and included in the discharge summary.
8 Referral notes: communication from referring hospital to more specialised levels of care (SBAR).
NOTES MADE AT THE ANTENATAL CLINIC
• Ensure with every visit that the antenatal card (page 2 of the Maternity Case Record) was completed correctly.
• Do not duplicate information already on the card in the notes, except when a full evaluation is made
during an acute admission/evaluation.
• Only make notes for additional, essential information that is not already entered on the antenatal card.
ACUTE EVALUATION (NOT FOR ADMISSION)
• Any pregnant patient consulted by a doctor (but not admitted as in-patient) with an acute problem should be
clerked with full Admission Notes with the relevant discharge plan authorised by an appropriate clinician.
ADMISSION NOTES (ACUTE ADMISSION)
Nursing Care Plan - upon admission, each patient must have an appropriate nursing care plan.
For patients received from EMS, any observations and problems experienced during transport must be included in the
clinical notes.
Admission notes should include:

• age, gravidity and parity, gestational age (and how it was calculated), or number of post-partum days (if applica-
ble)
• an immediate problem statement
• patient history, previous medical history, previous obstetric history, known allergies, social context, delivery
history if post-partum
• HIV status
○ if negative, date of last retest
○ if positive, most recent CD4 count, most recent viral load, current medication, date of inception of
medication
• Rhesus status
• syphilis status
• details of any current medication and allergy status
• observations (minimum requirement: blood pressure, heart rate, temperature, respiratory rate, urinary dipsticks)
• details of general examination
• details of abdominal examination (minimum requirement when antenatal: height of fundus, number of foetusfoe-
tuses, lie, side of the baby’s back, presentation, head-above-brim, clinical weight estimation). Height of fundus if
post-partum
• details of speculum examination (when indicated)
• details of vaginal examination (if indicated)
• if membranes ruptured, the time of rupture as well as the status of the draining amniotic fluid
• if foetalfoetal monitoring is indicated; the status of the latest CTG
• clinical risk assessment for specific risk assessments required/undertaken, including thromboembolic risk as-
sessment
• a list of all the problems identified
• a working diagnosis and care /treatment plan signed and dated. Clear nursing instructions, dated and signed,
must be made on the prescription chart in all cases and include as minimum:
○ intended ward for admission
○ general observations required and frequency thereof (according to standard nursing care plan, or more
frequently if clinically indicated)
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○ the action to take if any observation(s) are abnormal
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diet/fluid requirements as well as IV fluid requirements if indicated; NPO if indicated
○ whether CTG is indicated or not; the frequency thereof and whether it must be signed off by a clinician
when performed after hours
○ all medication (current and new) and all single dose/ stat drugs including prophylactic antibiotics, pre-op
medication and steroids where appropriate
FOLLOW- UP NOTES
Follow-up notes (following on the admission notes) should include:

• date and time of assessment, signed
• the gestational age/number of post-partum days on that day
• the current clinical problem
• the reason for continued admission
• the management plan for the next 24 hours
• the proposed discharge/delivery plan
HANDOVER NOTES: TRANSFER OF ACCOUNTABILITY
When the care of an acute obstetric in-patient is handed over to a next shift, a Transfer of Accountability Summary
must be made. This must include:
• date of the decision made to handover care
• the name and designation of the doctor who is now accepting responsibility for the patient’s further inpatient
care
• if there is a particular requirement to call a specific person from another discipline or special intervention team it
must be clearly noted
• identify the patient at high risk of clinical deterioration that will need an immediate response if called
• a short summary of the current problem
• the proposed management plan
• the new management plan (if adapted/changed at handover)
• when the next clinical review is due
INTRAPARTUM AND LABOUR WARD NOTES
• All patients in a labour ward must be assessed by an experienced health professional at minimum four hourly
and appropriate notes made according to the clinical situation.
• All patients in latent labour should be assessed by an experienced health professional at minimum four hourly
and the partogram and a relevant progress report completed.
• All patients in active labour should be assessed by an experienced health professional at minimum two hourly
and the partogram and a relevant progress report completed.
• All high-risk women should be seen by a doctor at least every four hours. In situations in which a professional
nurse seeks advice on a patient requiring emergency attention, that patient should be seen as soon as possible.
If that person is involved in another emergency, the second on call or the local protocol must be followed.
• All intrapartum notes must be dated and signed.
• All CTGs should be signed and dated/timed on the CTG when assessed, with a relevant classification made in
the notes; as well as the appropriate action taken or proposed.
REFERRAL NOTES USING THE SBAR (SITUATION-BACKGROUND-ASSESSMENT-RECOMMENDATIONS)

FORM
In the case of a telephonic consultation with a more senior colleague/referral hospital:

• use the national SBAR approach as a guide when consulting telephonically with a senior colleague (see
example at the end of the chapter).
DELIVERY NOTES
• If a clinician was actively involved in any part of the delivery itself, appropriate notes should be made directly
after the procedure.
• This note must make a pertinent mention of the foetal condition throughout the second stage.
• All instrumental deliveries must be documented using the standard pro-forma in the Maternity Case record.
SURGERY AND INVASIVE PROCEDURES NOTES
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• For patients undergoing surgery and/or invasive procedures, clinical records should include evidence that in-
formed consent has been obtained.
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Records should contain documented evidence of the discussion of the benefits, risks and complications of the
procedure, and alternative treatments.
• For a caesarean section and/or tubal ligation procedure, the relevant pro-forma in the Maternity Case record
should be completed.
• For all other surgery or invasive procedures a record of the operation should be made immediately after surgery
and must include:
○ date and time of the surgery
○ name of the operating surgeon(s) including the assistant even if they were medical students, health
professionals or clinical associates
○ name of the anaesthetist
○ the diagnosis made and the procedure performed
○ site and side of any operative procedure documented without abbreviation
○ description of the findings
○ details of the tissue removed, added or altered
○ details of sutures used
○ an accurate description of any difficulties or complications encountered and how it was dealt with
○ immediate post-operative instructions including site of post-operative care
○ the surgeon’s full signature, date and time
DISCHARGE NOTES
• For an antenatal discharge, there should be a clear summary of the management as in-patient and the
proposed further plan including a proposed delivery plan.
• For post-delivery discharge there should be a fully completed discharge summary available, including family
planning needs, referrals for breastfeeding/feeding support and plan(s) for future pregnancies. An example is
the pro-forma in the maternity care guideline for uncomplicated deliveries.
• Discharge summaries should already be filled in at the patient’s pinnacle of care (i.e. by the most senior
personnel) before she is stepped-down for further care.
• Once a patient is discharged (before delivery) and admitted at a later stage, a full assessment with a new
Admission Note should be made again.
ABBREVIATIONS IN NOTES
• Medication names cannot be abbreviated. Spell out drug names completely.

• Abbreviations cannot be used on consent forms.
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Figure 3.1 SBAR Clinical Report

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SBAR Clinical report on

Maternity situation
SITUATION
S I am calling about (name of woman) __________________________Ward:____________Hosp. No __________________

The problem I am calling about is __________________________________________________________________________
I just made an assessment of the pa8ent:
Vital signs:-‐ BP _____/_____ Pulse ______ resp rate _______ Oxygen satura8on _____% Oxygen at ____l/min Temperature _____ C
I am concerned about:
Blood pressure because: Urine output:
Systolic pressure greater than 160 mm Hg Output less than 100 ml over last 4 hours
Diastolic pressure more than 100 mm Hg Significant proteinuria (++/+++)
Systolic pressure less than 90 Haemorrhage
Pulse because: Antepartum
Pulse rate more than 120 Postpartum
Pulse rate less than 40 Fetal well being
Pulse rate greater than systolic BP CTG pathology
RespiraAon rate because:
Rate less than 10/min
Rate more than 24/min Early obstetric warning scores
BACKGROUND (Ack relevant secAons)
B The woman is:-‐

Parity [primiparous / mul8parous/ grand mul8parous] with gesta8on _______weeks and a [ singleton/ mul8ple] pregnancy
She had _____ previous caesarean sec8ons or episodes of uterine surgery
The present fetal assessment is :
Fundal height ________cm Presenta8on ________ with _____fi[hs head above brim: Fetal heart rate __________bpm
CTG : Not done / normal/ suspicious/ pathological
Antenatal risks
Risks iden8fied on antenatal card ________________________________________________________________________________
Labour
Not in labour / spontanious onset of labour/ induced labour
IUGR / Pre-‐eclampsia/ reduced fetal movements/ Diabetes/ Antepartum haemorrhage
On oxytocin infusion (_____IU/_______ml fluid given at ______ml/hour)
Most recent vaginal examina8on done at _______h Dilated ______cm with ______above brim and posi8on ___________
Membranes : Intact/ ruptured at _______h with currently clear / meconium stained liquor/ Blood stained liquor
Delivered ________________at _____h with 3rd stage complete/ retained placenta
Post Natal
Delivery date __________at ___________h____ Type of delivery ______________ With/ without perineal trauma
Blood loss ___________ ml Oxytocin infusion ______IU/ _________ml at ________ml/hour
Fundal height: High / Atonic/ Tender/ Abdominal-‐/ perineal wound oozing
Treatment given/ in progress
Rx __________________________________________________________________________________________________
ASSESSMENT
A I think the problem is ________________________________________________________________________________

The problem may be related to: Cardiac/infec8on/ respiratory/haemorrhage/PET/HELLP/Embolism/ Pulm edema/Fetal distress
I am not sure what the problem is, but the woman is deteriora8ng and we need to do something
RECOMMENDATION
R Request
Please come and see the woman immediately
I think delivery need to be expedited
I think the pa8ent need to be transferred
I would like advice on management of the pa8ent
Response
____________________________________________________________________________________________________________
Person comple8ng form: (name) _____________________________________Rank__________________Date_______ Time_______

PERSON REPORTED TO (Name) _______________________________Rank)____________________Inst_______________________
NB! A&er comple.ng and consulta.on, place this form in the pa.ent file as proof of communica.on and response
Figure 3.2: List of agreed abbreviations that can be used in clinical notes
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Common Medical and Obstetrical Conditions
AIDS Acquired Immunodeficiency Syndrome
APH Antepartum Haemorrhage
AROM Artificial rupture of membranes
Ca Cancer
CCF Congestive Cardiac Failure
COAD Chronic Obstructive Airways Disease
DVT Deep Vein Thrombosis
IUGR Intra-uterine Growth Restriction
MI Myocardial Infarction
MRSA Methicillin Resistant Staphylococcus Aureus
PE Pulmonary Embolus
PE Pre-eclampsia
PPROM Preterm premature rupture of membranes
PTL Preterm labour
ROM Rupture of membranes
TB Tuberculosis
UTI Urinary Tract Infection
Patient Investigation (Radiology)
AXR Abdominal X-Ray
CT SCAN Computerised Tomography
CXR Chest X-Ray
MRI Magnetic Resonance Imaging
U/S Ultrasound
Common Tests/Procedures
CPR Cardio Pulmonary Resuscitation
CPAP Continuous positive airway pressure
CTG Cardiotocograph
D&C Dilatation and Curettage
IOL Induction of labour
TPN Total Parenteral Nutrition
Medication/Drugs
IM Intra Muscular
IV Intravenous
Neb Nebulisation
PO By Mouth
PR Per Rectum
PV Per Vagina
S/C Sub Cutaneous
S/L Sub Lingual
IVI Intravenous Infusion
TTO To Take Out (Drugs)
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Equipment
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ET Tube Endotracheal Tube
IUCD Intra Uterine Contraceptive Device
NGT Naso Gastric Tube
TED Thrombo Embolic Deterrents
Patient Investigation (Blood)
FBC Full Blood Count
FFP / FDP Fresh Frozen Plasma/ Freeze Dried Plasma
HB Haemoglobin
K Potassium
Na Sodium
PCV Packed Cell Volume
PT Prothrombin Time
Rh Rhesus Factor
U+E Urea and Electrolytes
WCC White Cell Count
Patient Assessment/ Examination
BMI Body Mass Index
BP Blood Pressure
CNS Central Nervous System
CVP Central Venous Pressure
EFW Estimated fetal weight
NAD No Abnormality Detected
PMH Past Medical History
SOB Shortness Of Breath
Patient Investigation (General)
C&S Culture And Sensitivity
CSF Cerebro-Spinal Fluid
ECG Electro Cardiogram
LP Lumbar Puncture
MC&S Microscopy Culture And Sensitivity
MSU Mid-Stream Urine
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Chapter 4
ANTENATAL CARE
This chapter discusses the basic aspects of antenatal care, as a supplement to the national
BANC protocols. The BANC tick sheets and protocols should be used for all cases and
must be available in all facilities conducting antenatal care.
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PRINCIPLES OF ANTENATAL CARE
OBJECTIVES
Antenatal care attempts to ensure, by antenatal preparation, the best possible pregnancy outcome for women and
their babies. This may be achieved by:
• screening for pregnancy problems

• assessment of pregnancy risk
• treatment of problems that may arise during the antenatal period
• giving medications that may improve pregnancy outcome
• provision of information to pregnant women
• physical and psychological preparation for childbirth and parenthood
PRECONCEPTION CARE
This is the optimisation of a woman’s health or knowledge before she plans or conceives a pregnancy. All health workers
(not only midwives and obstetric doctors) who care for women in the reproductive age group need to consider the
possible effect of pregnancy on women they care for. Such women may be asked if there is a possibility of a pregnancy
in the near future. If pregnancy is not desired, appropriate counselling and advice on contraception may be offered.
If a woman is considering pregnancy, the following considerations will assist in preparing her in terms of her own health
and that of the baby that will be conceived:
• the presence of any medical conditions (including HIV) controlled or uncontrolled

• if HIV positive consider viral load values (<1000 copies per ml) before planning pregnancy
• medication or radiation needed as treatment for such conditions
• the past obstetric history
• nutritional issues, e.g. under nutrition or obesity
• immunity to rubella by previous exposure or vaccination
• family history and genetic risks
• use of tobacco, alcohol,cocaine and other recreational drugs
• possible occupational and environmental exposures
• social, economic and family issues
• mental health issues
While designated preconception clinics are not the norm in South Africa, all health workers who look after women in the
reproductive age have a responsibility to encourage women to make reproductive choices and assist those who are
considering pregnancy to optimise their health and knowledge appropriately.
RISK FOR GENETIC DISEASE
The following information should be provided to all women of childbearing age before conception:
• the risks of having a baby with chromosomal abnormalities with increasing maternal age, especially after 37
years
• the risks to the foetusfoetus of alcohol and recreational drug use by the mother
• the increased risk of abnormality when the parents are closely related
• the risks associated with a family history of genetic disorders
• the risks to the foetus of poorly controlled medical conditions in pregnancy
• the value of peri-conceptual folate in prevention of neural tube defects (five milligram daily three months prior to
conception continuing into the pregnancy)
• the risks to the foetusfoetus of maternal infections, e.g. rubella and syphilis, during pregnancy
• the risks to the foetusfoetus when the mother takes teratogenic medications during pregnancy
Women at risk for having a child with a birth defect or genetic disorder
• Refer as early as possible in the pregnancy for counselling regarding management and the performance of
prenatal tests.
THE MATERNITY CASE RECORD
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All pregnant women that present to a healthcare facility, public or private, should have, or should receive, a Maternity
Case Record (MCR). This standardised national document is the principal record of the pregnancy and it must be
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completed at each antenatal clinic visit and retained by the mother until delivery, after which it will be kept at the place
of confinement or final referral. It is not necessary for antenatal clinics to keep a duplicate record of the card. Only a
record of attendance, with results of special investigations, needs to be kept at the antenatal clinic for audit and backup
purposes. The MCR serves as official communication tool between the different levels of care and health facilities that
the client may visit during her pregnancy and should always be kept up-to-date.
RELATIONSHIP WITH PRIVATE CAREGIVERS
Private midwives, general practitioners and obstetricians are responsible for the pregnancy care of many South African
women. Dialogue and mutual respect should be encouraged between private caregivers and the government service.
Women that are referred from private providers to public service care should carry letters or cards that summarise all
relevant antenatal care up to that point. Ultrasound reports are particularly valuable, as they assist in accurate dating of
pregnancies.
THE FIRST ANTENATAL VISIT
CONFIRMATION OF PREGNANCY AND TIMING OF THE FIRST VISIT

A woman should visit her healthcare provider as soon as she suspects pregnancy, even as early as the first missed
menstrual period. Urine pregnancy tests must be available at all healthcare facilities. Women who present to primary
care clinics and are found to be pregnant must be issued with an antenatal card and receive first visit antenatal care.
Those who request termination of pregnancy should be appropriately counselled and referred.
THE IMPORTANCE OF THE FIRST ANTENATAL VISIT

Complete assessment of gestational age and risk factors can be made at the first antenatal visit. It is not necessary to
wait until the second visit before such assessments are finalised. After one visit, a pregnant woman can be regarded as
‘booked’.
At the first visit, find out what health care the woman has received so far in the pregnancy, especially from private
practitioners. If she has had previous antenatal care obtain information (records) from the provider, if possible and
regard that as the first visit.
HISTORY TAKING
Take a full and relevant history including:
• current pregnancy
• previous pregnancies, any complications and outcomes
• medical conditions, including psychiatric problems, and previous operations
• familial and genetic disorders
• allergies
• use of medications
• use of alcohol, tobacco and other substances
• family and social circumstances
PHYSICAL EXAMINATION
• Do a general examination including weight, height, heart rate, colour of mucous membranes, blood pressure, a
check for oedema, and palpation for lymph nodes.
• Do a systemic examination including teeth and gums, breasts, thyroid, and heart and lung examination. When
no staff member in the antenatal clinic has been trained to perform heart and lung examination, this may be
omitted provided the pregnant woman has no history or symptoms of heart or lung disease. Refer women with
dental problems to a dentist or dental therapist.
• Examine the pregnancy including inspection and palpation of the pregnant uterus; with measurement of the
symphysis-fundal height (SFH) in centimetres.
MID-UPPER ARM CIRCUMFERENCE
THE MEASUREMENT OF MID-UPPER ARM CIRCUMFERENCE (MUAC)

The MUAC gives useful information on nutritional status and pregnancy risk and is easily done during the antenatal
period or during labour. MUAC is advantageous over body mass index because height does not need to be measured,
accurate scales are not required, the woman does not have to stand up straight, no calculations need be done, and
MUAC, unlike weight, does not normally increase significantly during pregnancy.
A MUAC ≥33 cm:

• suggests obesity
• is associated with an increased risk of pre-eclampsia and maternal diabetes
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• is associated with an increased risk of delivery of a larger than normal infant
• indicates that blood pressure measurement with a normal-sized adult cuff may be an overestimation
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• suggests under nutrition or a chronic wasting illness
• is associated with delivery of a smaller than normal infant
How to measure the MUAC:

• measure the MUAC just before or just after checking the blood pressure
• use a soft tape-measure, as for symphysis-fundal height
• the arm should hang freely (elbow extended)
• measure the MUAC at any gestation, or during or after labour
• measure the arm circumference in either the right or left arm, midway between the tip of the shoulder (acromi-
on) and the tip of the elbow (olecranon). record the measurement to the nearest one millimetre
• record the MUAC in the MCR on the antenatal card (page 2)
What should be done if an abnormal MUAC is found?

A MUAC <23 cm should:
• raise vigilance for under nutrition or chronic illness, e.g. infection or neoplasia
• raise vigilance for foetal growth restriction, and careful SFH measurement and uterine palpation at all antenatal
visits
• ensure good nutritional status; refer for nutritional supplementation if needed
A MUAC ≥33 cm should:

• raise concerns about risks of hypertension and gestational diabetes
• raise concern about the risk of foetal macrosomia - disproportion, shoulder dystocia
• necessitate the use of a large sphygmomanometer cuff
ESTIMATION OF GESTATIONAL AGE
Indicate on the antenatal card (page 2 of the MCR) how the gestational age was estimated. The first estimation of
gestational age, with the expected date of delivery, should be used for the remainder of the pregnancy and must not be
changed unless important new information becomes available.
Last menstrual period

This is valid if the woman is sure of her dates, and where palpation of the uterus and SFH measurement are compatible
with the given dates (Figure 4.1, page 37). Gestation age must be calculated from the first day of the last menstrual
period.
Symphysis-fundal height (SFH) measurement

This is used for estimation of gestational age after 24 weeks if the dates from the last menstrual period are unknown or
wrong, in the presence of a normal singleton pregnancy. The measured SFH is plotted onto the 50th centile line on the
SFH graph, allowing the corresponding gestational age to be read from the graph (Figure 4.2, page 38).
Palpation
The SFH measurement is of little value for estimation of gestational age at less than 20 centimetres and more or
equal to 35 centimetres (corresponding to less than 20 weeks and term respectively). In early pregnancy, bimanual
and abdominal palpation can be used, and at term, palpation of the foetal head is of some value. Gestational age
assessment by palpation requires care, skill and experience.
Ultrasound
An ultrasound scan for gestational age estimation should be requested for women who are unsure of dates with SFH
measurement less than 24 cm. Foetal measurements by ultrasound give reasonably accurate gestational age esti-
mates before 24 weeks of gestation. Ultrasound after 24 weeks is less reliable, but in obese patients, it can still be
used up to 28 weeks.
ESSENTIAL SCREENING INVESTIGATIONS
• HIV serology, using rapid test kits. This must follow the national guidelines on routine counselling and voluntary
testing (see chapter 13).
• TB screening for both HIV positive and negative women at each antenatal visit.
• Syphilis serology. Rapid tests are preferable, as results are immediately available. Take care to follow the in-
structions from the manufacturer carefully to avoid false negative results.
• Rhesus (D) blood group, using a rapid test.
• Haemoglobin (Hb) level, using a portable haemoglobinometer or copper sulphate screening method. Repeat Hb
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measurements at 28-32 weeks geatational age.
• Urine dipstick testing for protein and glucose at each antenatal visit.
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All of the above tests can be performed by midwives or appropriately trained auxiliary staff at the clinic ‘on site’, with
the results provided to all antenatal attendees prior to their depature.
SCREENING TESTS THAT ARE NOT OFFERED ROUTINELY

Inform pregnant women that the following screening tests are not offered routinely, but which may be indicated in some
circumstances:
• ABO blood group
• screening for down’s syndrome (see chapter 14)
• rubella serology
• blood glucose screening (see section on diabetes)
• cervical (Papanicolaou) smear (follow the national screening guidelines)
• urine culture
• ultrasound scan (see chapter 15)
MEDICATIONS AND VACCINES

The following are given to all pregnant women (tick the appropriate block on the antenatal card when dispensed):
• ferrous sulphate tablets 200 mg daily, to prevent anaemia
• calcium tablets 1000 mg daily, to prevent complications of pre-eclampsia (e.g. calcium carbonate (168 mg) two
tablets orally, three times daily with food. this is best taken four hours before or after iron supplements
• folic acid tablets five miligram daily
• tetanus toxoid (TT) immunisation, to prevent neonatal tetanus:
○ first pregnancy: TT1 at first antenatal visit, TT2 four weeks later and TT3 six months later
○ later pregnancies: Two TT boosters, one in each pregnancy at the first visit, for the next two subsequent
pregnancies, at least one year apart
○ a total of five properly spaced doses of TT provide life-long protection against tetanus.
• If in a subsequent pregnancy, there is no record of previous immunisation, treat as for a first pregnancy
FINAL ASSESSMENT
The final assessment should include:

• check-list for risk factors (use the ‘BANC Clinic Checklist - Classifying (first) visit’ tick sheet- see figure 4.3 for
example) and a plan for further antenatal care and delivery at the appropriate level of care. A list of risk factors
is provided in figure 4.4
• a best estimate of gestational age, based on the evidence obtained from the date of the last menstrual period,
foetal palpation, measurement of SFH and ultrasound if available
• a plan for management or appropriate referral for any problems
INFORMATION FOR PREGNANT WOMEN
Certain essential information must be provided to all pregnant women, verbally and (where possible) in the form of
written or illustrated cards or pamphlets. This includes:
1. Five danger signs and symptoms of pregnancy

• severe headache
• abdominal pain (not discomfort)
• drainage of liquor from the vagina
• vaginal bleeding irrespective of amount
• reduced foetal movements
A woman that experiences any of these symptoms should report immediately to her clinic or hospital with her MCR.
2. Self-care in pregnancy
• healthy diet and exercise
• personal hygiene and breast care
• advice on sexual activity in pregnancy (use of condoms)
• be aware that self medication may be harmful. however continue taking prescribed medications including ART
if HIV positive, iron, folic acid and calcium supplements
• don’t abuse alcohol, tobacco and recreational drugs
3. A delivery plan
At the end of the first visit, all pregnant women should be given a provisional delivery plan:
• the expected date of delivery, based on the best estimate of gestational age
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• the expected place of delivery, whether community health centres or hospital
• the expected mode of delivery, whether vaginal or caesarean delivery
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who will deliver the baby, whether midwife or doctor
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• pain relief options including non-pharmacological methods
• a transport plan for an emergency or for the onset of labour , including important contact numbers
• the practice of home delivery should be discouraged; all women should try and deliver in a facility with a skilled
birth attendant
• all women with unknown HIV status will be tested at delivery
4. Newborn and infant care

• plans for infant feeding and techniques, whether breast or formula
• details of follow up care: immunisation and where this can be obtained
• future pregnancies and contraception
• information on genetic disorders and birth defects
• contraception that will be used after the pregnancy
• newborns exposed to hiv or born to hiv infected mothers must have a pcr test at birth
• the PCR test should be repeated at ten weeks and a antibody test done at 18 weeks of birth
SUBSEQUENT ANTENATAL VISITS
SCHEDULE FOR RETURN VISITS

• A ‘basic antenatal care’ schedule of four follow-up visits is provided for women without any risk factors.
• Following the early booking visit (preferably <12 weeks), return visits should be scheduled for 20, 26-28, 32-34,
and 38 weeks, and 41 weeks if still pregnant by then (see figure 4.5).
• This is not applicable for women with risk factors or who develop a risk factor during pregnancy, whose return
visits schedules will depend on their specific problems.
CONTENT OF SUBSEQUENT ANTENATAL VISITS

• Ask about general well-being, foetal movements, danger symptoms and any problems.
• Check the blood pressure, heart rate and colour of the mucous membranes.
• Measure the symphysis-fundal height (SFH) in cm. Plot the SFH on the graph against the gestational age and
compare with the 10th, 50th and 90th centiles for gestational age and with previous measurements.
• Palpate the presenting part from 34 weeks; palpate carefully for possible breech presentation at 34-36 weeks.
• Test the urine for protein and glucose at each visit.
• Repeat syphilis and HIV tests at 32 weeks for all women who tested negative at initial testing.
• Repeat blood tests: Hb at 32 and 38 weeks.
• Provide HCT every three months for all HIV negative women and those who had previously declined to test.
• Repeat information for danger signs pregnancy, and review delivery and transport plans, as well as feeding and
contraception choices.
• At 38 weeks, remind the woman to bring her MCR with her when she presents to the clinic or hospital in labour.
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Figure 4.1: Antenatal card of a woman with certain (correct) dates
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At booking (25 February 2014) she was 22 weeks pregnant by dates. The SF measurement of 20cm is in keeping with
her dates. SF growth is normal, just above the 10th centile.
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Figure 4.2: Antenatal card of a woman with uncertain dates At booking (11 March 2014) the SF height of 26cm
was plotted on the 50th centile, giving a gestational age of 27 weeks. SF growth is close to the 50th centile
and appears normal.
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Figure 4.3: Clinic checklist – classifying (first) visit
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Figure 4.4: Check list of risk factors requiring referral or hospital delivery
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Figure 4.5: Clinic checklist: Booking & follow-up of hiv negative patient
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Chapter 5
LABOUR AND DELIVERY
This chapter discusses the steps to take to support all aspects of labour from diagnosis to
delivery. It also discusses abnormalities and emergencies during labour, and performing a
caesarean section.
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CHAPTER 5: NORMAL LABOUR AND DELIVERY

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SKILLED ATTENDANCE AT BIRTH AND MOTHERS’ WAITING AREAS
Health services should make every effort to ensure skilled professional attendance at birth for all pregnant women.
Mothers’ waiting areas are boarding facilities at Community Health Centres (CHCs) and district hospitals where women
with advanced pregnancy may stay until they go into labour. Such facilities should be established in rural areas and in
districts where transport problems and remoteness make it difficult for women to access skilled attendants at birth.
DIAGNOSIS OF LABOUR
Labour is diagnosed if there are persistent painful uterine contractions accompanied by at least one of the following:
• change in cervical effacement and dilatation

• ruptured membranes
• show
Latent phase: the woman is in labour and the cervix is <4 cm dilated and ≥1 cm long.
Active phase: the woman is in labour and the cervix is ≥4 cm dilated and <1 cm long.
Sometimes one cannot be immediately certain if the woman is in the latent or active phase.
ADMISSION OF A WOMAN IN LABOUR
History taking
• Carefully review the antenatal record, especially the gestational age, blood results and HIV status. Clearly note
all the risk factors. Interview “unbooked” women as if they are attending antenatal clinic for the first time.
• Note the nature of labour pains, show, vaginal bleeding, fetal movements, passage of liquor and any other
relevant symptoms.
Physical examination
• Note the psychological state, heart rate, temperature, blood pressure, respiratory rate and any oedema or
pallor.
• Examine the abdomen:
○ inspect for previous scars, possible multiple pregnancy or abnormal lie
○ measure the symphysis-fundal height in centimetres
○ determine the foetal lie (longitudinal, oblique or transverse), presentation (cephalic or breech) and attitude
of the head (the amount of flexion or extension)
○ level of the presenting part in fifths palpable above the pelvic brim
○ liquor volume (probably normal if the foetal head is ballottable)
○ uterine tone, and duration and frequency of uterine contractions
○ auscultation of the foetal heart before and immediately after a contraction
○ clinical estimation of foetal weight.
• Perform a vaginal examination:
○ vulva and vagina: look for abnormal discharge, warts or ulcers
○ cervix: effacement (length in cm), position, consistency, and dilatation in cm
○ membranes ruptured or not and whether there is meconium-stained liquor
○ the presenting part: its position, degree of sagittal (parietal-parietal or PP) moulding and caput
Special investigations
• Test the urine for glucose, ketones and protein.
• Perform rapid syphilis and rhesus group testing in “unbooked” women or women whose results are not availa-
ble.
• Provide HIV counselling and testing if no result is available.
• Measure the Hb if no recent result (<4 weeks) is available.
• Perform HIV test to those of unknown HIV status , those who tested negative and those who declinedtesting
earlier in pregnancy. Manage results according to the National Consolidated PMTCT Guidelines or refer to
Chapter 13 of these guidelines.
GENERAL CARE OF WOMEN IN LABOUR
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Assessment of problems and risks
Note risk factors and problems and consult or refer to a district hospital depending on the specific problem. Women at
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low risk (absence of any factors listed in figure 4.4 in chapter 4) should be able to give birth at a CHC.
Respect, privacy and companionship

Treat all women in labour with respect and courtesy. Address the women by her name. Ensure privacy and always
perform intimate examinations behind screens, with a chaperone if needed. Allow family and friends to provide
companionship during labour.
Diet and fluids

Allow low-risk women to eat and drink during labour. An intravenous drip is not needed. High risk women (figure 5.7,
page 65) require an intravenous drip of ringer’s lactate to run at 80-120 mL/hour, but are allowed to take clear fluids.
Mobility and posture

Encourage women in the latent phase of labour and early active phase to walk around. Any posture (sitting, standing,
lying) is acceptable, except the flat supine position (lying on the back), which may compress the aorta and vena cava,
causing low blood pressure and reduced blood flow to the uterus.
Enema, pubic hair shaving and insertion of urinary catheter

None of these procedures is necessary or desirable in the routine management of normal labour.
Artificial rupture of membranes (amniotomy)

Amniotomy may contribute to neonatal infection and HIV transmission and should not be part of the routine
management of normal labour.
Partogram
During the active phase of labour, all observations, fluid intake and output, and medications must be entered on the
partogram. Latent phase observations may be entered on the partogram or on a separate observation sheet.
ROUTINE MONITORING IN THE FIRST STAGE OF LABOUR
Latent phase (cervix <4 cm dilated):

• temperature, heart rate, respiratory rate and blood pressure four hourly
• uterine contractions and foetal heart rate four hourly
• vaginal examination four hourly
Any change in phase of labour, or abnormal observation, warrants more frequent observation or action.
Active phase (cervix ≥4 cm dilated, <1 cm long):

• Maternal condition
○ heart rate, BP, respiratory rate hourly
○ temperature four hourly
○ urine volume and test for protein and sugar when urine is passed
• Foetal condition
○ foetal heart rate half-hourly, before and immediately after contractions, ideally using a hand-held doppler
device
○ colour and odour of the liquor two hourly if the membranes have ruptured
• Progress of labour
○ duration and frequency of uterine contractions half-hourly, per ten minutes
○ vaginal examination two hourly noting cervical dilation, sagittal moulding and caput
• Treatment given
○ all medications
○ all fluids, by whatever route
• Summary of findings
○ identified problems
○ management plan
The partogram: alert and action lines

Record all findings of maternal and foetal condition, and progress of labour, on the partogram. As soon as the active
phase of labour is diagnosed, place the first entry for the active phase at the point where the recorded cervical dilatation
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is exactly on the alert line. Alternatively, on a blank partogram where there are no pre-drawn lines, draw an alert line at
a slope of one cm/hour from the first cervical dilatation in the active phase.
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The action line is drawn two hours to the right and parallel to the alert line, and represents the extreme of poor progress
where ‘action’ is mandatory (e.g. transfer from a CHC to hospital, oxytocin infusion, caesarean section).
Examples of completed partograms are shown in figure 5.8, page 66.
Analgesia in labour
Pain relief should be offered to all women in labour:
• support and companionship have been shown to reduce the need for analgesic medication in labour. promote
companionship in labour
• pethidine 100 mg with promethazine 25 mg intramuscularly four hourly is acceptable in both the latent and ac-
tive phases, even up to full dilatation of the cervix
• inhaled entonox® (a mixture of 50 per cent nitrous oxide and 50 per cent oxygen) by mask is useful in the late
first stage (≥8 cm cervical dilatation)
• epidural anaesthesia is generally not available in CHCs and district hospitals. Some institutions may however
have the necessary skills and equipment to provide this form of pain management
MANAGEMENT OF THE SECOND STAGE OF LABOUR
The second stage starts when the cervix reaches full dilatation (10 cm) and ends with delivery of the baby. Time (up to
two hours) can be allowed for the head to descend onto the pelvic floor if foetal distress and cephalo-pelvic disproportion
(CPD) have been ruled out. The bladder should be empty or emptied, using a catheter if necessary. The observations of
the active first stage of labour should continue. Efforts at bearing down are only encouraged when the foetal head starts
to distend the perineum and the woman has an urge to push.
When the woman is ready to push (bear down):

• always communicate clearly with the woman to gain co-operation
• be supportive and encouraging
• put the woman in a suitable position: propped up, sitting, squatting, kneeling, semi-Fowler’s or wedged supine.
Avoid the flat supine position (lying flat on the back), as the pregnant uterus will compress the aorta and inferior
vena cava
• encourage pushing/ bearing down only during contractions
• listen to the foetal heart after every second contraction
• protect the perineum when the foetal head crowns
• dry the baby and place the baby on the woman’s abdomen, skin to skin, for her to hold immediately after
delivery for at least an hour. Postpone all routine neonatal procedures that are not lifesaving (e.g. washing,
weighing and non-urgent medical procedures)
• help the mother to initiate breastfeeding within an hour after birth (which can decrease the risk of maternal
haemorrhage, new-born hypoglycaemia and increase exclusive. breastfeeding) unless there is a medical
indication not to breastfeed
• assess the baby’s Apgar score at one minute
• wait one to two minutes before clamping the umbilical cord, but clamp and cut the cord earlier if the baby needs
urgent resuscitation
• record the times of onset of the second stage, onset of bearing down efforts and delivery, as well as the status
of the foetal heart rate during the delivery
Episiotomy
Routine episiotomy is discouraged. Consider episiotomy only for the following reasons:
• thick or rigid perineum preventing delivery and prolonging the second stage
• foetal distress in the second stage of labour
• maternal conditions where rapid delivery is required, e.g. cardiac disease
• breech or forceps delivery
• previous third degree tear
• preterm delivery where the perineum is tight
Local anaesthetic (lignocaine 1 per cent solution, maximum 20 ml) must be infiltrated into the perineum before cutting
the episiotomy. Perform a mediolateral episiotomy, where the cut is started in the midline at the fourchette, bearing
laterally at about 45 degrees. Avoid median or lateral or bilateral episiotomy.
Repair of episiotomy
• polyglactin is recommended. Use 1/0 to 2/0 absorbable sutures
• place a vaginal tampon high in the vagina with an artery forceps attached
• make sure that the anal sphincter is not disrupted
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• insert a suture close to the apex of the episiotomy in the vaginal epithelium
• from the apex down, close the vaginal epithelium with a continuous suture
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ensure correct alignment by checking the apposition of the hymen and the vaginal-perineal junction
• approximate the perineal muscles and fascia with interrupted sutures
• close the skin with interrupted sutures or a continuous subcutaneous suture
• always remember to remove the vaginal tampon and record this in the notes
• do a rectal examination after suturing, check for any stitches placed in the rectum and record the absence of
any sutures in the notes. Remove any sutures found in the rectum and repair again (use clean gloves)
MANAGEMENT OF THE THIRD STAGE OF LABOUR
The third stage starts immediately after delivery of the baby and ends with delivery of the placenta. The active method
of managing the third stage is recommended, to prevent excessive bleeding:
• immediately after delivery of the baby, ensure by abdominal palpation that there is no previously undiagnosed
second twin, even if antenatal ultrasound found a singleton pregnancy
• if there is no second twin, immediately give oxytocin ten units intramuscularly
• await uterine contraction for two to three minutes then feel for uterine contraction every 30 seconds
• do not massage or squeeze the uterus with the placenta still inside
• when the uterus is felt to contract, put steady tension on the umbilical cord with the right hand, while pushing
the uterus upwards with the left hand
• deliver the placenta by applying continuous gentle traction on the umbilical cord
• examine the placenta for completeness and for any abnormalities
MANAGEMENT OF THE FOURTH STAGE OF LABOUR
The fourth stage is defined as the first hour after delivery of the placenta. The woman is at risk for postpartum
haemorrhage and must be observed closely:
• check and record the woman’s heart rate, BP, respiratory rate and temperature just after delivery of the placenta
• regularly check that the uterus is well contracted
• ensure frequently that there is no excessive vaginal bleeding
• show and encourage the woman how to rub her own uterus to maintain contraction assist the woman with her
baby, encouraging her to hold it, skin to skin, and put it to the breast unless the woman has decided not to
breastfeed
• record the women’s heart rate, respiratory rate and BP measurement after one hour
• at the end of the fourth stage, offer the woman a light meal and transfer her to the postnatal ward if all
observations are normal
• to those “who were admitted with the cervix fully dilated and delivered” or had a “BBA” perform HIV testing
according to the National HIV testing guidelines
ABNORMALITIES OF THE FIRST STAGE OF LABOUR
PROLONGED LATENT PHASE OF LABOUR

The latent phase of labour is prolonged when it exceeds eight hours in a birth facility. Prolonged latent phase can
be difficult to diagnose, but is likely if there are cervical changes and increasing uterine activity over eight hours of
observation.
Management of apparent prolonged latent phase

• Exclude other causes of abdominal pain, e.g. abruptio placentae, urinary tract infection.
• Consider false labour, characterised by no cervical changes and no increase in duration, regularity or frequency
of labour pains. Women with false labour may be discharged home if there are no other obstetric problems.
• If certain that the woman has a prolonged latent phase, exclude foetal distress and CPD, then ‘stretch and
sweep’ the cervix, rupture the membranes and/or start an oxytocin infusion as for active phase augmentation
(figure 5.1). Transfer the women from the CHC to the hospital.
POOR PROGRESS IN THE ACTIVE PHASE OF LABOUR

There is poor progress if the cervix dilates at a rate of <1 cm/hour in the active phase (crosses the partogram alert
line). Partograms illustrating poor labour progress are shown at the end of the chapter.
Management of poor progress in the active phase

• Use the rule of 4Ps in the assessment (Patient, Powers, Passage, Passenger).
• Ensure adequate maternal hydration: Give a bolus of Ringer’s lactate (200-300 mL intravenously) and continue
with an IV infusion of Ringer’s lactate to run at 120 mL/hour.
• Ensure that the bladder is empty: catheterise if necessary.
• If there is evidence of CPD in a multipara (increasing grade of sagittal moulding with no descent, or grade two
sagittal moulding with the head ≥3/5 palpable above the brim), arrange caesarean section or transfer from CHC
to hospital.
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• Exclude malpresentation: for breech and oblique/transverse lie, arrange caesarean section or transfer from
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CHC to hospital.
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• Exclude foetal distress (late decelerations, thick meconium): if the foetusfoetus is in distress, do immediate cae-
sarean delivery or transfer from CHC to hospital urgently.
• With good hydration, bladder empty, no CPD in a multipara, no malpresentation and no foetal distress:
○ Support and reassure the woman
○ Offer analgesia
○ Rupture the membranes if still intact
○ Continue labour observations as before and reassess progress two hourly
• If progress crosses the two hour action line:
○ transfer from CHC to hospital
○ if no CPD in a primigravida and no evidence of foetal distress, start oxytocin infusion
• Continue with two hourly assessments: if progress in cervical dilatation is still less than one cm/hour,
• Perform caesarean delivery.
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Figure 5.1 Oxytocin for induction or augmentation of labour

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EARLY WARNING CHART
Use pa'ent s'cker
Ins'tu'on_____________________________________ Name:
Hosp no:
WARD_____________________________________
Chart Number _____ DOB:
CONTACT DOCTOR FOR EARLY INTERVENTION IF PATIENT TRIGER 1 RED or 2 AMBER SCORES AT ANY ONE TIME
Month Date (Day)
Time
Person doing observa'on
> 30
Resp rate (write rate in 25-‐30
box) 15-‐24
0-‐14
95-‐100%
O2 Satura'on
<95%
Aministered O2 (L/min)
40
Temperature
39
38
37
36
35
HR > Systolic BP
160+
150
140
130
Heart rate
120
110
100
90
80
70
60
50
40
200+
190
180
Systolic Blood pressure
170
160
150
140
130
120
110
100
90
80
70
60
50
140+
130
12
110
Diastolic BP
100
90
80
70
60
50
40
30
Passed Urine Y/N
Unine
Urine volume
++
Proteinuria
>++
No
Looks unwell
Yes
Alert
Vocal
Neuro response
Pain
Unresponsive
None -‐ mild
Pain
Moderate-‐severe
Normal
Lochia Heavy (H) fresh(F)
Offensive O
Clear (C) Pink (p)
Amnio'c fluid
Green (G)
Total amber
Total res
CONTACT DOCTOR FOR EARLY INTERVENTION IF PATIENT TRIGER 1 RED or 2 AMBER SCORES AT ANY ONE TIME
Document any ac@on on abnormal observa@ons on the back of this observa@on chart
MECONIUM STAINING OF THE LIQUOR

Thin (grade 1) meconium staining of the liquor (MSL) requires no special management. Intrapartum passage of thick
(grade 2-3) MSL is associated with an increased risk of fetal distress:
• transfer from chc to hospital
• monitor the foetusfoetus with a CTG continuously in labour
• before delivery, ensure readiness for neonatal resuscitation and suction of meconium from the trachea
• deliver normally at vaginal birth or caesarean section, and resuscitate and suck meconium only if the baby is
not vigorous
• for babies not breathing adequately, suck meconium from below the cords under direct vision using a neonatal
laryngoscope and meconium aspirator
FOETAL MONITORING
• For low risk labour, listen to the foetal heart with, ideally, a hand-held Doppler device, or a foetal or normal
stethoscope, before and immediately after contractions.
• CTG is used for high risk labour only (figure 5.2) and must be available in all hospitals. CTG monitors are not
recommended for intrapartum use in CHCs.
• After CTG interpretation, write a note about the findings in the woman’s notes, so that a record of the CTG is
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still available even if the CTG tracing is lost.
• All CTG tracings must be kept safely in the woman’s file and be stored with the file after delivery.
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Figure 5.2 Common indications for CTG monitoring in labour
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ABNORMALITIES OF THE SECOND STAGE OF LABOUR
PROLONGED SECOND STAGE OF LABOUR

The second stage is prolonged if:
• the foetal head has not descended onto the pelvic floor after two hours of full dilatation
• delivery has not occurred after 45 minutes of pushing in a nullipara, or 30 minutes of pushing in a multipara
If the woman is not bearing down after one hour of full dilatation:
• re-examine the woman to make sure the cervix is truly fully dilated
• rupture the membranes if they are intact
• attempt delivery by asking the woman to bear down
• if these efforts do not result in delivery efforts at a CHC, transfer to hospital; unless skills and equipment for
vacuum extraction are available (see below)
• exclude CPD or foetal distress: if found, arrange caesarean section
• consider oxytocin infusion for nulliparous women only
• continue routine monitoring of labour
• re-assess after one hour: if still no delivery efforts, do vacuum extraction if the head has descended to the pelvic
floor or caesarean section if head is ≥2/5 palpable above the brim
Failure of the head to descend despite maternal pushing

If delivery has not occurred after 45 minutes of pushing in a nullipara, or after 30 minutes in a multipara:
• take care with assessing the level of the head: excessive caput or moulding may give the impression that the
head is deep in the pelvis when it is not truly engaged. Use fifths palpable above the brim to assess head
descent
• perform ventouse delivery if the head is 0/5 or 1/5 palpable above the brim, if necessary with oxytocin infusion.
Transfer from CHC to hospital if skills and equipment are not available for ventouse delivery , or if the foetal
head is >1/5 palpable
• arrange for emergency caesarean delivery or transfer from CHC to hospital if the head ≥2/5 palpable above the
brim
VACUUM EXTRACTION/VENTOUSE DELIVERY
Vacuum extraction (ventouse delivery) may be performed at CHCs by experienced advanced midwives and in hospital
by advanced midwives and doctors. Disposable vacuum cups are preferred because they are easy to use and reliable.
Conditions for safe vacuum extraction

• Woman fully informed and co-operative.
• Vertex presentation.
• Foetal Head 0/5 or 1/5 palpable above the brim (0/5 only at a CHC).
• Certainty about the position of the presenting part.
• Cervix fully dilated.
• Membranes ruptured.
• Bladder empty.
• Strong uterine contractions (duration >40 seconds duration).
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Technique
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Ventouse delivery techniques vary with different equipment and operators:
• check the equipment thoroughly before use by testing suction on the gloved hand
• aim for a negative pressure of at least -0.6 Bar to -0.8 Bar in the cup (do not exceed a pressure of 0.8 Bar/80
Kilopascal/600 mmHg- the red zone on the disposable cups)
• apply traction only during contractions
• the ventouse delivery has failed if:
○ there is no noticeable head descent during traction
○ the head has not delivered after three pulls (one pull = one contraction) with functioning equipment
○ there have been two cup detachments with functioning equipment
• failed ventouse delivery requires caesarean delivery unless the baby’s head has already extended and can be
easily delivered by pushing without further use of the ventouse
• document /record the procedure fully: indication, initial findings, times, cup type and size, number of pulls,
number of detachments and baby’s condition at delivery
FORCEPS DELIVERY
Forceps delivery should only be performed in hospitals, by experienced operators, where all conditions for forceps
delivery are met.
CAESAREAN SECTION/ DELIVERY
All district hospitals should have staff and facilities for the performance of a caesarean delivery 24 hours a day.
Surgical techniques vary according to the circumstances and the experience of the operator. All hospitals should be
able to perform an emergency caesarean section within one hour of the decision to operate.
Requests by pregnant women for caesarean delivery (CD)

Caesarean delivery is associated with an increased risk of maternal infection, haemorrhage, thromboembolism,
postpartum death, and obstetric complications in subsequent pregnancies. Women who request a CD and have no
clinical indication for the operation should be counselled about the risks and benefits of the procedure.
Women who ask for CD and have a relative indication, e.g. previous CD, may be booked for CD after counselling. In
general, the performance of CD without a valid indication is unacceptable practice.
Foetal maturity testing before elective caesarean delivery with uncertain gestational age
If elective (non-urgent) caesarean delivery is planned for a woman at term, and the gestational age is uncertain but
apparently close to term, foetal lung maturity testing may be helpful. After performing amniocentesis, amniotic fluid is
sent to the laboratory to assess surfactant content. The local laboratory will first need to be consulted to ask what foetal
lung maturity tests, if any, they perform.
Alternatively, consider doing a foam test at the bedside:
• obtain a sample of amniotic fluid, in which there is no visible trace of blood or meconium
• add one mL of amniotic fluid to one mL of 95 per cent alcohol in a clean dry test tube; cover with clean plastic or
plastic top (not rubber)
• shake the tube vigorously for 30 seconds
• tap the side of the tube to get rid of large bubbles
• examine the meniscus (surface) of the fluid mixture 30 seconds after shaking, holding the tube upright
• if at least a thin and complete ring of foam remains on the meniscus, the foetusfoetus is likely to have mature
lungs and is unlikely to develop hyaline membrane disease
• absence of an adequate ring of bubbles suggests that the foetus is immature, but sometimes does occur with a
mature foetus. Rather postpone the procedure for a week
Preparation and precautions before caesarean delivery

• Obtain signed informed consent for surgery with the operation and its indication clearly explained to the woman.
• Ensure that emergency blood for transfusion is available in the hospital.
• Measure the woman’s Hb level.
• Ensure an experienced operator is available to do, or to assist at, caesarean deliveries in the second stage of
labour.
• Consider transfer to a specialist hospital if difficulties with surgery are expected, e.g. placenta praevia, previous
myomectomy, abruptio placentae with a dead baby, transverse lie, morbid obesity and serious co-existing
medical or surgical conditions.
Just before starting the operation, ensure that:
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• Tubal ligation has been considered, and informed consent obtained if requested by the woman.
• The foetal heart can still be heard.
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• The indication for the CD is still valid.
• Broad-spectrum intravenous antibiotics have been given. These may be either prophylactic or therapeutic an-
tibiotics. Routinely, a dose of prophylactic antibiotics (e.g. cefazolin 1g) is given pre-op, irrespective of whether
the operation is an emergency or elective procedure, and there is no need to give further doses of antibiotics
post-op. If, however, the patient has evidence of intra-uterine sepsis, or there are factors which put her at high-
risk of post-operative sepsis, then intravenous therapeutic antibiotics (e.g co-amoxyclav 1,2g) should be started
pre-op and continued post-op for five days, although intravenous antibiotics could be changed to oral antibiotics
after a few days depending on the patient’s condition.
Indications for therapeutic rather than prophylactic antibiotics include:
• severe immunocompromise (e.g. history of recent AIDS defining illness or CD4 <250)
• evidence of chorioamnionitis (including offensive liquor)
• prolonged labour with many per vaginal examinations after rupture of membranes
• obstructed labour (will usually have systemic signs of sepsis)
• caesarean delivery following failed vacuum extraction
Haemorrhage at caesarean delivery

At CD, excessive bleeding and its complications can be prevented by:
• having an experienced surgeon available or transferring to specialist care pre-operatively if severe bleeding is
anticipated, e.g. placenta praevia or caesarean delivery in the second stage of labour
• having blood for transfusion available if Hb <10 g/dL pre-operatively
• routinely giving oxytocin 2.5 mg IV immediately after delivery of the baby (anaesthetist)
• delivery of the placenta by cord traction, not manual removal
• good surgical technique, including careful haemostasis
Manage excessive bleeding at CD as follows:
• call for help.
• remove excessive blood with suction or swabs.
• inform the anaesthetist to provide uterotonics, fluid resuscitation and blood replacement if needed.
• determine whether blood loss is from an atonic uterus, placental site, or from bleeding incisions or tears.
• if blood loss is from an atonic uterus, proceed as for atonic uterus after vaginal delivery.
• if blood loss is from the placental site (e.g. placenta praevia):
○ place square sutures in the placental bed
○ consider a brace suture (e.g. B-Lynch suture), systematic devascularisation, balloon tamponade or
hysterectomy
○ if hysterectomy is required but cannot be done, tie a Foley catheter around the uterus (to arrest bleeding)
and await help or transfer to specialist care
• if blood loss is not from an atonic uterus:
○ define all anatomy well
○ remove sutures if necessary to expose bleeding areas
○ arrest bleeding with figure-of-eight sutures; if possible, avoid placing sutures near the ureters in the base
of the broad ligament
○ consider systematic devascularisation or subtotal hysterectomy
○ consider other causes of bleeding, e.g. ruptured liver in pre-eclampsia
○ with persistent bleeding from the uterus, tie a Foley catheter tightly around the uterine lower segment
including the broad ligaments and wait for help, or transfer to specialist care for hysterectomy. Ensure that
blood pressure and heart rate are stable before transfer
Postoperative orders
• Prescribe analgesia:
○ opiate, e.g. papaveretum (Omnopon®) 20 mg intramuscularly with prochlorperazine 12.5 mg
intramuscularly four to six hourly when necessary for 24 hours
○ indomethacin 100 mg suppository 12 hourly, or ibuprofen 400 mg orally three times daily (not in patients
with asthma, peptic ulcer or kidney dysfunction) for two or three days when necessary
○ paracetamol one gram orally four times daily when necessary
• Prescribe intravenous fluids: Ringer’s lactate one litre with 20 units oxytocin over eight hours, then Maintelyte®
or 5 per cent Dextrose-saline one litre over eight hours.
• Prescribe ongoing doses of therapeutic antibiotics for five days in women who have evidence of infection or are
at high risk of infection, (see indications above( p 59)).
• Give prophylaxis against thromboembolism for women at risk (sodium heparin 5 000 units subcutaneously
12-hourly or enoxaparin 40 mg SC daily while in hospital). Risk factors to consider are advanced maternal age,
obesity, HIV infection, pre-eclampsia, immobility and co-existing illnesses.
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FOETAL DISTRESS
Foetal distress is suspected when the foetal heart rate is abnormally high or low, or if decelerations are heard, or a
CTG tracing is suspicious or pathological.
Management of foetal distress

• Explain the problem to the woman.
• Perform a vaginal examination for cervical dilatation and to exclude cord prolapse:
○ if the cervix is fully dilated, deliver normally or by vacuum extraction
○ if there is cord prolapse manage appropriately (see below)
○ if delivery is not imminent, proceed as below
• Place the woman in the left lateral position.
• Stop oxytocin infusion if applicable.
• Give oxygen by face mask at 6 L/min for 20-30 minutes.
• Start an IV infusion of Ringer’s lactate to run at 240 mL/hour for one to two hours, unless the woman is hyper-
tensive or has cardiac disease.
• Give salbutamol 250 μg (½ of a 500 μg ampoule diluted in 20 mL saline) IV slowly.
• Transfer from CHC to hospital and monitor with CTG.
• If a pathological tracing persists, arrange emergency caesarean delivery .
CORD PROLAPSE
In cord prolapse, the umbilical cord comes out of the cervix in front of the foetal presenting part, with the membranes
ruptured. Frequently, the cord may appear at the vulva.
If the foetus is alive (foetal heart heard) and viable:

• call for help
• explain the problem to the woman
• perform vaginal examination
If the cervix is fully dilated and the foetal head has engaged in the pelvis immediately deliver the baby by
vacuum extraction or forceps delivery if necessary.
If the cervix is not fully dilated, arrange for urgent CD or for transfer from CHC to hospital, and proceed as
follows:
• replace the umbilical cord in the vagina and try to keep it inside the vagina using sanitary pads and closing the
mother’s thighs
• handle the cord as little as possible
• if the presenting part is felt to be compressing the cord, push the presenting part up with the fingers, and turn
the woman to a knee-elbow position with the fingers continuing to hold the presenting part of the cord, if neces-
sary
• insert a urinary catheter, at least size 18 G, and empty the bladder
• fill the woman’s bladder with 400 mL of normal saline and clamp the catheter
• start an IV infusion of Ringer’s lactate
• give Salbutamol 250 μg (½ of a 500 μg ampoule diluted in 20 mL saline) IV slowly as a single dose
• if the presenting part is not compressing the cord, place the woman in a left lateral (Sims) position with a pillow
under the hips
• make accurate notes of all that has been done, with times
• before starting the caesarean delivery ensure that the foetus is alive
• if the foetus is dead or not viable, and there is no other indication for caesarean delivery, await vaginal birth
SHOULDER DYSTOCIA
In shoulder dystocia delivery of the baby’s head is not followed by delivery of the rest of the body because the shoulders
are too broad and become stuck in the pelvis. This usually happens with large babies (>3.5 kg). Emergency management
is as follows:
• call for at least two assistants
• explain the problem to the woman
• immediately move the woman to the edge or to the lower end of the delivery bed
• help the woman to hyper flex the hip joints (McRoberts’ position). Her knees should almost touch her shoulders
• apply downward suprapubic pressure
• tell the woman to push, even if she does not have a contraction
• gently guide the head downwards to help delivery but do not stretch the neck or jerk forcefully on the head
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• if unsuccessful so far, deliver the posterior arm by locating the posterior shoulder in the vagina and sweeping
the arm in front of the baby’s chest. Once the posterior arm is delivered, delivery of the anterior shoulder should
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• if the posterior arm cannot be easily delivered, insert a loop of plastic tubing, e.g. urine bag tube or feeding
tube, through the posterior axilla of the baby and pull down on the loop until it becomes possible to deliver the
posterior arm as above
• posterior arm delivery may be easier if the woman turns to a knee-elbow position (all-four position)
• an alternative method is to rotate the baby through 180 degrees to bring the posterior shoulder forward. During
rotation hold both the arm and the head to facilitate rotation and reduce the risk of injury to the baby
• if delivery has not been achieved at this point the baby is likely to die. If the baby is dead, await spontaneous
delivery and call for help or advice to deliver the baby without injuring the woman
• irrespective of the outcome for the baby, debrief the woman after the delivery, giving a full explanation of the
emergency management and potential complications
ABNORMALITIES IN THE THIRD AND FOURTH STAGES
THIRD DEGREE PERINEAL TEAR

In a third degree tear the anal sphincter is disrupted and there may be injury to the rectal mucosa (fourth degree tear).
It is important after every vaginal birth to inspect tears and episiotomies well to identify third degree tears. Women with
third degree tears must be transferred from a CHC to a district hospital. If there is no expertise at the district hospital,
transfer to a specialist facility.
Repair of a third-degree tear

• The repair should be performed by an experienced doctor in theatre, ideally using spinal anaesthesia.
• Use polyglactin absorbable suture: repair the rectal mucosa first with 3/0 suture, continuous or interrupted.
• Follow this by repairing the rectal muscularis layer with 3/0 suture, continuous or interrupted. Include the internal
anal sphincter in this suture.
• Identify the disrupted ends of the external anal sphincter on each side just above the anal verge and extract and
hold them with Allis clamps.
• Repair the external sphincter with four simple 2/0 sutures, either as an end-to-end or as an overlapping
anastomosis.
• Complete the repair as for episiotomy.
• Give antibiotic prophylaxis – ampicillin one gram IV six hourly for 24 hours followed by amoxicillin 500 mg orally
three times daily, with metronidazole 400 mg orally three times daily, for a total of five days.
• Give oral analgesia e.g. paracetamol one gram orally six hourly or ibuprofen (if not contraindicated) 400 mg
orally eight hourly for three to four days.
• Prescribe stool softeners e.g. ispaghula (Agiolax®), or bran, or lactulose 10g twice daily orally for five days.
Advise on a high fibre diet and pelvic floor exercises.
• Write a clear discharge summary with clear instructions for a follow-up doctor visit.
RETAINED PLACENTA
The placenta is retained when it is not delivered from the uterus within 30 minutes of delivery of the baby. At times, the
placenta is not truly retained, and it may be removed by simply lifting it out of the vagina, or manually helping it out of
the cervix.
Management of retained placenta

• Insert a urinary catheter.
• Start an infusion with oxytocin 20 units in 1L Ringer’s lactate at 120-240 mL/hour.
• Observe the woman constantly for vaginal bleeding or placental delivery.
• If there is excessive vaginal bleeding insert a second intravenous line as fluid resuscitation and attempt manual
removal of the placenta if the cervix is sufficiently open or if the placenta is partially expelled.
• If the placenta cannot be delivered or if it has not been delivered after one hour of oxytocin infusion, arrange for
manual removal under general anaesthesia, or transfer from CHC to hospital.
• Take blood for Hb and cross match.
• For manual removal try to remove the whole placenta with the hands. Use the ulnar surface of the palm to
create a cleavage plane. If instruments are required to remove retained cotyledons or products, use the largest
available forceps and curettes to prevent uterine perforation.
• Call for help if bleeding persists or if placenta accreta is suspected, or transfer to specialist level facility after
stabilising the patient.
• Give ampicillin one gram IV followed by amoxicillin 500 mg three times daily orally and metronidazole 400 mg
three times daily orally for five days.
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PRIMARY POSTPARTUM HAEMORRHAGE

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This is defined as excessive blood loss from the genital tract during the first 24 hours after delivery. Postpartum
haemorrhage (PPH) is considered mild with blood loss from 500-1000 mL, severe with blood loss from 1000-2500 mL,
and massive with blood loss of >2500 mL. However, estimating blood can be subjective and may not be accurate.
POSTPARTUM HAEMORRHAGE AFTER VAGINAL DELIVERY

Prevention
PPH and its complications can be prevented by:
• ensuring skilled attendance at delivery if necessary by providing maternity waiting homes in rural areas
• iron supplementation in pregnancy and antenatal screening and treatment of anaemia
• partogram-based management of the first stage of labour to prevent prolonged labour
• routinely practising active management of the third stage of labour
• identifying women at risk for atonic uterus and giving additional oxytocin (20 units in 1L Ringer-Lactate at 120-
240 mL/hour) after active management of the third stage
• close observation of vital signs, uterine contraction and bleeding in the fourth stage of labour
Management of PPH after vaginal delivery

All women with PPH must be transferred from a CHC to hospital. CHC midwives and doctors should take whatever
emergency steps they can, as listed below, to arrest bleeding and achieve fluid resuscitation. Patients with PPH must,
wherever possible, be adequately stabilised before transfer from CHC to hospital.
Stepwise management of PPH should proceed as follows:

• call for help and rub the uterus to expel clots and induce contraction
• start a rapid infusion with one litre Ringer’s lactate solution in one arm
• in the other arm start oxytocin 20 units in one litre Ringer’s lactate at 240 mL/hour
• insert an indwelling urinary catheter
• check placenta: if retained or incomplete, proceed as for retained placenta discussed above
Look for the cause of bleeding by examining the woman’s abdomen:

• atonic uterus: suggested by a large soft uterus: add ergometrine 0.5 mg IM or Syntometrine® one ampoule
IM (if not contraindicated by cardiac disease or hypertension) and massage the uterus continuously; if clots are
retained in the uterus, remove them manually
• lacerations: suggested by a well contracted uterus with fresh bleeding. The lacerations need to be repaired
following examination of the entire birth canal, in the lithotomy position, under anaesthesia if necessary. If the
apex of a cervical laceration cannot be reached from a vaginal approach, suspect uterine rupture and perform
laparotomy for definitive repair, foley catheter tourniquet or total hysterectomy.
• uterine inversion: suggested by inability to feel the uterus through the abdominal wall and can be confirmed by
performing a vaginal examination. Uterine inversion needs immediate reduction.
If haemorrhage from an atonic uterus cannot be controlled:

• continuously massage the uterus and manually remove newly formed clots
• apply bimanual pressure to the uterus if necessary
• continue with oxytocin infusion and give one repeat dose of ergometrine or syntometrine®
• continue fluid resuscitation and order blood for transfusion
• give tranexamic acid 1 g IV over 10 minutes (also useful with lacerations)
• inject prostaglandin F2-alpha 0.5 mg into the myometrium as follows: dilute a five miligram ampoule in 10 mL
water and inject one mL through the skin into the uterine fundal myometrium; avoid in asthma and cardiovascu-
lar disease. Can repeat up to a total dose of 2.5 mg (5 mL)
• insert a condom catheter (an open condom slipped over a large Foley catheter and secured at its base with
string to provide a makeshift balloon catheter) into the uterus, inflate with 400-500 mL of saline and clamp; and
pack the vagina with swabs to prevent expulsion. Transfer for urgent further specialist care or (if stable and
bleeding has stopped) observe for 8-12 hours before removal of the catheter.
• if oxytocin and ergometrine are not available or if the uterus will not contract in response to all of the above
measures, give misoprostol 400 mg sublingually as a single dose
• with further bleeding, arrange for urgent examination in theatre with manual exploration of the uterus for rupture
and for retained products, and possible laparotomy with brace suture (B-Lynch or Hayman), systematic devas-
cularisation (uterine and ovarian arteries), or hysterectomy
• if unable to do hysterectomy and with persistent bleeding from the uterus, tie a Foley catheter tightly around the
uterine lower segment, including the broad ligaments, and transfer to specialist care for hysterectomy. Ensure
that blood pressure and heart rate are stable before transfer
• as a last resort, apply firm and sustained pressure to the aorta above the level of the umbilicus while awaiting
help or while attempting to control bleeding points surgically
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Inserting a B-Lynch brace suture

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• This may be done for PPH after normal delivery or after caesarean section.
• Put the woman in a modified Lloyd Davies position (thighs spread but not flexed much), to allow surgery while
observing for vaginal bleeding.
• Exteriorise the uterus and open the lower segment (if not already open) with a transverse incision.
• Explore the inside of the uterus for bleeding points and place figure-of-8 sutures over any single large bleeding
points.
• Compress the uterus with the hands. If this stops the bleeding, a B-Lynch brace suture (alternative is Hayman
sutures) is likely to be successful.
• Use a single 1 metre length of thick absorbable suture material (chromic or polyglycolic 1 or 2) with a large
needle.
• Ensure that the assistant compresses the uterus well while the suture is tightened and tied.
Figure 5.3: B-Lynch brace suture (from www.gyncph.dk/procedur/obstet/blynch.htm)
Anterior view: the stitch is

inserted below the right angle of
the uterine incision
2
Posterior view: the right and left braces
pass over the fundus and are joined
by the suture passing across the lower
3 segment through the posterior uterine
wall, at the level of the uterosacral
ligaments
B-Lynch brace suture (from
www.gyncph.dk/procedur/
obstet/blynch.htm) Suture completed and uterus compressed.
The stitch emerges below the left angle
of the uterine incision with the knot in the
midline below and anterior to the incision
ACUTE INVERSION OF THE UTERUS

This emergency requires immediate action. Acute uterine inversion may be caused by inappropriate cord traction on a
fundal placenta in a flaccid uterus, without providing the necessary upward counter-pressure on the uterus. At times it
occurs spontaneously. Clinical shock may be greater than expected for the amount of blood loss.
• Immediately treat shock with Ringer’s lactate given through one or two lines using large bore (16G) IV cannulas.
• Order blood for transfusion if there is haemorrhage.
• Give pethidine 50-100 mg IV if systolic BP≥90 mmHg.
• Do not remove the placenta if it is still attached to the uterus.
• Give salbutamol 250 μg (½ of a 500 μg ampoule diluted in 20 mL saline) IV to relax the uterus.
• Place the flat hand against the inverted surface of the uterus and push the uterus (with placenta if attached)
as high up into the vagina as possible and hold that position for several minutes. Reduction should occur with
sustained upward pressure.
• If reduction is not achieved, attempt reduction by filling the vagina with 500-1000 mL of saline, using a soft
vacuum cup or other device to provide an external seal.
• Once reduction is achieved, give ergometrine 0.5 mg IM and oxytocin 20 units in one L Ringer-Lactate at 240
mL/hour. Do not remove the hand from the uterine cavity until a firm uterine contraction is felt.
• Carefully deliver the placenta when signs of separation are observed.
• If the placenta is not expelled spontaneously from the uterus, manual removal needs to be done in theatre.
• Observe the woman closely for haemorrhage or re-inversion.
• Failed reduction requires laparotomy. Using Allis clamps pull on the round ligaments where they enter the
uterine constriction ring, with an assistant pushing the inverted uterus up from below.
• A tight constriction ring may prevent reduction. At laparotomy, the ring can be opened by a one centimetre low
vertical posterior incision in the uterus. Then proceed as discussed in the point above.
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HAEMORRHAGE AFTER CAESAREAN DELIVERY

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Haemorrhage during caesarean delivery is discussed above under caesarean delivery /section. PPH may occur after
the operation in the theatre recovery area or in the postnatal ward. Haemorrhage may be internal (intraperitoneal,
extraperitoneal), or external (vaginal). Internal bleeding can be difficult to diagnose clinically - be aware of a post-CS
patient with tachycardia and tender abdomen, as the Hb does not drop immediately and the bleeding is concealed.
PPH after CD can be prevented by:

• all the steps above for preventing haemorrhage at caesarean section (above)
• routinely checking all incisions and tubal ligation sites for bleeding before closing the abdominal cavity
• by ensuring (with the anaesthetist) that the mother’s pulse rate is less than 100/minute, systolic BP is greater
than 100 mmHg and that the respiratory rate is less than 24 /minute before closing the anterior abdominal wall.
Any abnormality of the vital signs requires a call for help
• routinely giving oxytocin 20 units in one litre Ringer’s lactate over the first eight hours postoperatively
• routinely rubbing the uterus and expelling clots immediately after completing the CD
• regular postoperative observation of general condition, BP, heart rate and pad checks
• intensive observation (in high care) of women who had excessive bleeding at caesarean section or who are at
risk for further haemorrhage
Manage excessive bleeding after caesarean delivery as follows:

• record general condition, heart rate, respiratory rate and BP
• insert one or two large bore IV lines and resuscitate with Ringer’s lactate
• insert a urinary catheter
• determine the cause of bleeding:
○ if the uterus is atonic, massage the uterus (this can be painful) and evacuate clots, then give uterotonics as
for atonic uterus after vaginal delivery (as above)
○ if the uterus is well contracted, arrange a “re-look laparotomy” and proceed as for
○ haemorrhage at CD (as above)
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Figure 5.4: Postpartum haemorrhage (PPH) after vaginal birth

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Prevention
• After vaginal delivery:
Postpartum haemorrhage
Oxytocin 10 U IM after
(PPH) after vaginal birth
delivery, then controlled
cord traction
• At risk for PPH:

Consider oxytocin
infusion or ergometrine
in addition to above
Resuscitate
• Rub up uterus and expel clots
• Call for help
• Insert 2 large IV cannulae
• Oxytocin 20 U in 1 L Ringer’s lactate
• Urinary catheter
• Maintain BP with clear fluids/blood
• Monitor BP, pulse, urine output

Undelivered Placenta Incomplete

• Repeat cord traction • Uterine evacuation
• Manual removal • Digital exploration
• Ovum forceps and
Complete largest curette

Soft (atonic) Uterus Not felt

• Massage uterus, expel clots • Check vaginally for
• Continue oxytocin infusion inverted uterus
• Ergometrine 0.5 mg IM • Replace immediately
• PGF2α 0.5 mg inject into • Hydrostatic reduction
myometrium Firm with saline infusion into
• Tranexamic acid 1 g IV • Suture lacerations vagina – seal the vulva
• Misoprostol 400 μg of perineum,
sublingual vagina or cervix

• Balloon tamponade
Ongoing bleeding
• Examine in theatre* *With no theatre
• Explore for retained products facilities, patient will
• Explore for ruptured uterus need emergency
• Balloon tamponade transfer. Balloon
• Laparotomy: catheter may be
- B-‐Lynch suture inserted into the
- Tranexamic acid 1 g IV uterus.
- Artery ligation
- Hysterectomy
- Foley catheter tie
- Hysterectomy
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Figure 5.5: Bleeding at caesarean delivery

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Figure 5.6: Bleeding after caesarean delivery

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Prevention Diagnosis
• Haemostasis at • Excessive vaginal
caesarean delivery Bleeding after caesarean bleeding
• Regular postop deliveryd • Pallor, tachycardia, low
monitoring BP
• Special monitoring in • Abdominal distension
high-‐care area for
women at risk of
postop bleeding
RESUSCITATE
• Second IV line
• Oxytocin infusion 20 U/L
• Maintain BP with fluids and
blood
Atonic uterus Uterus well

• Massage uterus and remove clots contracted
• Add ergometrine 0.2 mg IV (not if
cardiac or hypertensive)
• PGF2α 0.5 mg inject into
myometrium Still bleeding LAPAROTOMY
• Misoprostol 400 μg sublingual Lloyd-‐Davies position
• Pallor, tachycardia, low BP
Abdominal distension

Atonic uterus Bleeding from uterine incision Placental site bleeding
• B-‐Lynch suture • Single bleeding area: insert suture • Square sutures
• Subtotal • Continued bleeding and/or bleeding from • B-‐Lynch suture
hysterectomy whole incision: reopen uterus, inspect • Tranexamic acid 1 g IV
• Balloon tamponade
placental bed and resuture
• Stepwise devascularisation
• Bleeding from lateral extension of uterine • Hysterectomy
incision: uterine artery ligation
NB: proceed immediately to

subtotal hysterectomy if
patient very unstable
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Figure 5.7: Problems requiring referral from chc to hospital during labour or postpartum
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Figure 5.8: Completed partogram

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Chapter 6
BLEEDING IN EARLY PREGNANCY

This chapter discusses the importance of and methods for treating bleeding in early
pregnancy, the various forms of miscarriage and ectopic pregnancy.
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CHAPTER 6: BLEEDING IN EARLY PREGNANCY

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Early pregnancy complications are usually neglected because they are often not seen as part of the maternity skills
package. Complications in early pregnancy however require specific skills best provided by competent midwives and
medical practitioners appropriately trained to manage any problems in early gestation.
Seven to 10 per cent of pregnancies are associated with complications in early gestation and account for 5.2 per cent
of all institutional maternal deaths recorded in South Africa. Facilities providing maternity service must have a system in
place to ensure that women with early pregnancy complications are managed by health professionals with the relevant
skills.
Miscarriages are usually spontaneous but could be induced processes. Induced miscarriages (termination of pregnancy)
could have been done through legal or illegal sources.
BLEEDING IN EARLY PREGNANCY

Bleeding in early pregnancy is defined as vaginal bleeding that occurs within the first 22 weeks of gestation. Follow
the steps below for diagnosis and treatment:
Do a rapid assessment of the patient including:

• vital signs: pulse rate, respiration rate and BP
• abdominal assessment: tenderness, size of uterus
• other: vaginal examination, pallor, assess the extent of vaginal bleeding (vaginal bleeding is regarded as
“heavy” if a new pad is soaked within five minutes and “light” if it takes more than five minutes to soak)
Assess for complications

• if shocked, the patient needs active resuscitation
• determine if the patient has had a safe or unsafe miscarriage (see below)
Differential Diagnosis
• Pregnancy test positive: consider miscarriage, ectopic pregnancy or molar pregnancy.
• Pregnancy test negative: consider pelvic inflammatory disease (PID), torsion of an ovarian cyst, acute
appendicitis.
Safe miscarriages are those unlikely to have a serious adverse outcome to the patient. Unsafe miscarriages are more
likely when done illegally or where existing conditions makes it likely for the women to develop sepsis.
Figure 6.1: Problems associated with vaginal bleeding

VAGINAL BLEEDING
Light bleeding Heavy bleeding

Cervical os closed Cervical os dilated
Cramping / Lower Adnexal mass/ Uterus smaller Uterus corresponding Uterus larger
abdominal pain Cervical motion than dates to dates than dates
Uterus smaller Uterus corresponding Partial expulsion No products of Partial expulsion

than dates to dates of products conception of products
Complete Threatening Etopic Incomplete Inevitable Molar pregnancy

miscarriage miscarriage pregnancy miscarriage miscarriage
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MISCARRIAGE
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Safe miscarriage
Normal vital signs:
• Pulse rate <90 beats per minute
• Respiratory rate <20 breaths per minute
• Temperature <37.5°Celsius
• Haemoglobin ≥10g/dl
Uterus <12 weeks in size
Products of conception not foul smelling
No clinical signs of infection
No suspicious findings on evacuation of the uterus
Safe miscarriages can be managed at community health centres and district hospitals. If there is any abnormality
among the criteria for safe miscarriage, stabilise and refer the patient to a district hospital with a 24-hour theatre
available. If there is any organ dysfunction present, stabilise and refer urgently to a specialist facility.
Signs of organ dysfunction with miscarriage

Systolic blood pressure <90mmHg
Respiratory rate >24 breaths per minute
Oliguria (urine output <30mL for 2 hours despite fluid load)
Signs of tissue hypoperfusion:
• Altered mental status
• Decreased capillary filling
Miscarriage is a clinical diagnosis and ultrasound is not needed to make this diagnosis. I there is cervical
bleeding and the cervical os is open with products palpabble,the uterus must be evacuated.
THREATENING MISCARRIAGE
Mild bleeding in early pregnancy without cervical dilatation can indicate a threatening miscarriage. The uterus size
corresponds to the expected gestation.
• surgical treatment is usually not needed.
• not necessary to admit patient to hospital.
• advise the woman to avoid strenuous activity and any sexual activity.
• if bleeding stops, continue antenatal care as scheduled.
• if the bleeding continues, assess for fetal viability with ultrasound examination. This should be done by a skilled
professional.
COMPLETE MISCARRIAGE
After a complete miscarriage the bleeding is usually mild and the cervical os closes. The uterus on palpation is smaller
than expected for the gestational period.
• Medical treatment or surgical evacuation of the uterus is usually not needed.
• Advise the woman to report any continuous bleeding and make a booking for post-miscarriage follow-up.
INEVITABLE MISCARRIAGE
When a threatening miscarriage progresses, the volume of vaginal bleeding increases and the cervix dilates. This is
usually associated with an increase of cramping lower abdominal pains.
In pregnancy less than 16 weeks gestation:

• plan for evacuation of uterine contents
• if evacuation is not immediately possible:
○ give ergometrine 0.2 mg intramuscularly (repeated after 15 minutes if necessary) / Syntometrine® OR
○ misoprostol 400 µg by mouth (repeated once after four hours if necessary); then arrange for evacuation of
uterus as soon as possible.
In pregnancy greater than 16 weeks:

Wait for spontaneous expulsion of the products of conception.
• If products are incomplete on inspection, evacuate the uterus to remove any remaining products of conception.
• If necessary, infuse oxytocin 20 units in one litre intravenous fluids (normal saline or Ringer’s lactate) over eight
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hours to help achieve expulsion of products of conception.
• Make sure the woman is booked for follow-up after treatment.
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With an incomplete miscarriage, the cervix remains open, products of conception may be visible or felt, and the
bleeding may be light or heavy. The uterus size does not correspond with the gestation.
In pregnancy less than 16 weeks:

• if the bleeding is light, remove visible products of conception with fingers or a ring forceps (swab holding
forceps) and observe. If bleeding remains light, no further action will be required
• if the bleeding is heavy after visible removal of products of conception the uterus must be evacuated
○ manual vacuum aspiration is the preferred method of evacuation if the uterine size is <12-14 weeks. (Sharp
curettage should only be done if MVA is not available or possible)
○ if evacuation is not immediately possible give ergometrine 0.2 mg IM or misoprostol 400 µg orally to reduce
the risk of severe bleeding while arranging the evacuation
In pregnancy greater than 16 weeks:

Later in the pregnancy, chances are better that complete spontaneous expulsion of the products of conception may
occur.
• Set up an intravenous line and infuse oxytocin 20 units in 1 litre ringers lactate every eight hours until expulsion
of the products of conception occurs.
○ Misoprostol 200 µg orally four hourly may be given if the abortion does not progress on oxytocin (maximum
800 µg).
• After expulsion, examine the uterus and evacuate any remaining products of conception.
UNSAFE MISCARRIAGES
Unsafe miscarriages should not be managed at community health centres or district hospitals without appropriate
operative facilities.
Any miscarriage with a significant tachypnoea (respiration rate above 24/minute) should be diagnosed as a septic
abortion/miscarriage and must be referred immediately to a specialist facility. Commence with the standard sepsis
miscarriage management protocol.
MANAGEMENT OF A SEPTIC MISCARRIAGE
Septic miscarriages should be managed at a specialist hospital; make immediate arrangements for the transfer and
discuss with the receiving facility. Stabilise before referral as follows:
• do a rapid assessment of the patient- circulation, airway and breathing
• insert an intravenous infusion and start rehydration with Ringer’s lactate or normal saline
• prescribe antibiotics and give the first dose before transfer:
○ ampicillin or Cephalosporin (usually one gram six hourly intravenously). Use Clindamycin (600 mg eight
hourly intravenously) as alternative for penicillin allergy
○ metronidazole 400 mg three times per day orally
• reduce the toxic load through surgical removal of source within two to four hours after commencing antibiotics
• if the patient is shocked (pulse rate > systolic blood pressure), determine if the shock is due to hypovolemia or
sepsis:
○ give one litre Ringer’s lactate rapidly over 20 minutes in an attempt to raise the blood pressure levels and
decrease the pulse rate
○ if the blood pressure value increases and the pulse rate normalises, it is most likely hypovolemic shock due
to haemorrhage. Continue resuscitation
○ if there is poor response (blood pressure values do not increase), repeat with another litre of Ringer’s
lactate
○ if there is still no response in spite of adequate fluid therapy, the patient is in septic shock
All women in septic shock with organ dysfunction MUST be managed at a specialist hospital.
POST-MISCARRIAGE/ABORTION FOLLOW-UP
Women who have had a miscarriage must be provided with appropriate information.
• Inform her that spontaneous miscarriage is common and occurs in oneout of every seven pregnancies.
• Reassure her that the chances of a subsequent pregnancy being successful are good (unless the pregnancy
was complicated by sepsis or a recurrent cause for the miscarriage has been identified).
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• Women should only consider a next pregnancy after full recovery from the miscarriage.
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Any Miscarriage with a pulse rate exceeding the systolic blood pressure must be regarded as shocked
and resuscitation must start immediately
Women who have had an unsafe miscarriage must be counselled regarding the factors that affected her pregnancy, and
how to prevent this in future. Appropriate counselling must be done for family planning and the methods available to her.
• Hormonal pills, injections, implants as well as intrauterine devices and tubal ligation may be provided
immediately.
• Implants,intrauterine devices and surgery should be delayed if:
○ infection is present or suspected. Delay until such infection is cleared
○ severe anaemia (Hb <7g/dL). Delay until anaemia has improved
Screen for other health problems and correct if needed:

• anaemia
• Rh factor (if unknown) and Rh prophylaxis if Rh negative
• sexually transmitted diseases (including HIV). All women must be offered HIV counselling and testing
• ask patient to return for a Pap smear
Management of miscarrages is based on treating the underlying pathology and to prevent further
complications. This is done irrespective of the miscarriage, either spontaneous or induced.
Management of miscarriages is one of the key signal functions that should be rendered at any of the basic or
comprehensive emergency obstetric care centres.
MANUAL VACUUM ASPIRATION TECHNIQUE
Manual Vacuum Aspirations (MVA) is the best technique for the removal of products of conception in women with
incomplete abortions, inevitable abortions prior to 16 weeks gestation, molar pregnancies or delayed post-partum
haemorrhage due to retained placental fragments.
Advantages of MVA:
• can be done as an out-patient procedure
• does not require anaesthesia or an operation theatre
• significantly reduces blood loss and the need for blood transfusion
Initial steps:
• inform the patient of the diagnosis and treatment options
• obtain informed written consent
• the patient must empty her bladder just before the procedure
• provide emotional support and encouragement
• provide pre-procedure analgesics: Paracetamol 500 mg 30 minutes before the procedure
When starting the procedure:

• make sure the bladder is empty
• prepare a Karman syringe with the vacuum by locking the plunger arms
• give the patient 10 units oxytocin intramuscularly to make the myometrium firmer
• perform a bimanual examination to assess the size and position of the uterus
• insert a vaginal speculum and clean the vagina and cervix with an antiseptic solution (water based)
• check the cervix for tears or products of conception. (If products are visible, remove with a sponge holding
forceps)
• gently grasp the anterior lip of the cervix with sponge holding forceps
• gently introduce the widest gauge suction cannula through cervical os, push the cannula into uterine cavity until
it touches the fundus (max 10 cm) and pull back slightly
• attach the MVA syringe to the cannula and release the valves to transfer vacuum to the uterine cavity
• evacuate uterine contents by gently rotating the syringe and moving the cannula backward and forward
• check for signs of completion:
○ red or pink foam but no more tissues
○ a grating sensation
○ uterus contracts around the cannula
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• withdraw the cannula. Empty contents of the syringe into a strainer
• remove the speculum and perform bimanual examination to check the uterus size and firmness
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Note: The absence of products of conception raises a strong possibility of an ectopic pregnancy.
Post procedure care

• give analgesia (Paracetamol 1 g six hourly orally as needed)
• encourage the woman to eat, drink and walk around as she wishes
• offer other health services before discharge:
○ family planning
○ HIV and syphilis testing and counselling
○ Rh blood group screen if not known
Discharge the patient in one to two hours if there are no complications and advise her to watch for symptoms that
would require immediate action. Ask the patient to return if she experiences:
• prolonged cramping (more than two days)
• prolonged bleeding (more than two weeks)
• bleeding more than a menstruation
• severe or increasing pain
• fever, chills or malaise
• fainting
It is important to carefully document all actions, procedures and observations.
Be aware of illegal practices in the community of providing misoprostol to pregnant women to terminate
pregnancies. All women should be advised of such practices and risks associated with inappropriate use
of misoprostol.
ECTOPIC PREGNANCY
A woman with a positive pregnancy test and an acute abdomen mostly likely has a ruptured ectopic pregnancy. This is a
surgical emergency and the patient must be taken to the operating theatre immediately for explorative laparotomy. Order
blood, but do not wait for the blood to arrive before doing the laparotomy. Ultrasound may assist with the diagnosis,
especially if it shows an empty uterus and free fluid in the abdomen, but with an acute abdomen the investigation of
choice is surgery. If ultrasound and serum beta-HCG is not available and the diagnosis is doubtful, a culdocentesis may
be of value; if non-clotting blood is obtained, start treatment immediately.
Surgical management of a ruptured ectopic pregnancy

• Do adequate fluid resuscitation on the way to theatre, but do not delay surgery to try and correct the fluid
balance first- see anaesthetic notes. The woman is bleeding actively and unless you stop the bleeding
surgically, she will die.
• Do a midline (up-and-down) incision in the abdomen, as there may be other unexpected pathology. A
Pfannenstiel incision allows very limited exposure and should only be used for elective surgery or if the site of
the ectopic pregnancy can be clearly identified on ultrasound.
• Be careful not to damage the bowel when opening the peritoneum as the bowel will be pushed against the
peritoneum by the blood clots in the abdomen.
• Use a large suction and your hand to remove as much blood clots as possible to quickly visualise the tubes; if
there is too much blood put your hand behind the uterus and feel on which side the ruptured tube is.
• Clasp the ruptured tube between your fingers to temporarily stop the bleeding; then remove all the clots until
you have good visibility.
• Identify both ovaries and make sure they are left intact (except if one is involved in the mass). Inspect the other
tube and the uterus.
• If there is extensive damage to the tube, the surgery of choice is partial or total salpingectomy, removing the
pregnancy and the tube at the same time.
• Apply clamps on both sides of the ectopic or ruptured tube with 45 degree angles to the tube, so that their
points touch.
• Excise the ruptured part and then gently tie off each clamp, ensuring good haemostasis. Be careful not to
damage or tear the very friable tissue below the tube, as it will cause more bleeding.
• As soon as haemostasis is obtained, remove all the remaining clots and rinse the abdomen with saline. Inspect
the rest of the abdomen and remove all swabs. Inform the anaesthetist of the amount of blood loss.
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• Close the abdomen. Do not do any additional surgery at this stage- the patient can be referred at a later stage
for reconstructive tubal surgery if the fimbriae were not removed.
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In your notes, state which side was removed and how much, the condition of the remaining tube and of the
ovaries, and if any additional pathology was present.
Anaesthetic management of an unstable ruptured ectopic pregnancy

• When a patient is too unstable for a referral to a specialist centre, but the anaesthetic skills to manage such an
unstable patient are not available at the district hospital, the management of such a case is difficult.
• A spinal anaesthetic must not be administered, as the cardiovascular effects of such an anaesthetic will lead to
severe shock and possibly death.
• Initial attempts to stabilise the patient to a suitable condition for transfer should be made. If the patient has not
responded to two litres of Ringers Lactate then surgery will need to be performed urgently.
• Mobilise the most skilled practitioners available to assist with this case.
• Prepare theatre and all resuscitation equipment.
• Assess patient and the potential for a difficult airway.
• Monitor the patient with ECG, NIBP and Pulse oximeter.
• Pre-oxygenate with 100 per cent oxygen anaesthesia.
• Induce anaesthesia by administering Etomidate 0.3 mg/kg intravenously or ketamine two milligram/kilogram
intravenously (provide cricoid pressure if the skills are available).
• Suxamethonium 100 mg intravenously can be given by practitioners confident of intubation.
• The trachea should be intubated.
• Capnography and agent analysis should be utilised (confirm position of the tube by capnograph trace, and aus-
cultation of both axillae and over the stomach.)
• Ventilation should be provided at 12 breathes per minute and 400 mL tidal volume. Where possible PEEP of five
centimetreH2O should be applied.
• Isoflurane 0.3 to 1.0 per cent should be titrated to provide anaesthesia.
• Muscle relaxation should be provided by giving Vecuronium 0.1 mg/kg (only after intubation and commence-
ment of satisfactory ventilation).
• After the abdomen is opened and the bleeding controlled attempt further resuscitation with fluid and blood.
• Once the Systolic blood pressure is >100 mmHg, one miligram IV morphine titration each five minutes can be
commenced until 0.1 mg/kg has been given. Treat any resulting hypotension with further fluid and blood admin-
istration.
• Reverse the muscle relaxation with 2.5 mg of Neostigmine and 0.4 mg glycopyrrolate once spontaneous move-
ment has been observed to occur.
• Discontinue the isoflurane and allow the patient to extubate herself.
• If the patient does not stabilise after clamping the abdominal bleeder and fluid resuscitation keep the patient
intubated and ventilated for transport to a more specialised level of care.
• This method of anaesthesia will be associated with a high incidence of awareness. Counsel the patient with
respect to this if it occurs.
• If the skills exist to provide more complete and effective anaesthesia this description should not be followed.
However without appropriate training and skills providing a more potent anaesthetic combination to a shocked
patient could result in harm.
A stable, unruptured ectopic can be referred to a specialist centre for medical or laparoscopic management,
but it remains an urgent referral as the tube can rupture on the way.
Unruptured ectopic pregnancy Ruptured ectopic pregnancy

Symptoms and signs of early pregnancy. Patient haemodynamically Haemodynamically unstable patient (low blood pressure, tachycardia,
stable. tachypnoea, collapse, weakness, pallor).
Abdominal and pelvic pain. Acute abdominal and pelvic pain.
Tenderness with vaginal examination. Abdominal distension.
Rebound tenderness; marked cervical excitation tenderness.
If there is access to ultrasound and serum beta HCG (human chorionic gonadotrophin), it is much easier to diagnose
doubtful, early and stable ectopic pregnancies:
• If the serum beta HCG is ≥1500 mIU/mL and the uterus is empty on ultrasound, there is a pregnancy of unknown
location (ectopic) and further work-up and surgery is needed.
• If the serum beta HCG is <1500 mIU/mL and the uterus is empty in an otherwise stable patient, it may be a very
early normal pregnancy or an ectopic pregnancy. Keep the patient for observation and repeat the beta HCG 48
hours later.
○ if the beta HCG value doubles in 48 hours it is most likely an early intra-uterine pregnancy and ultrasound
can be repeated in two weeks’ time
○ if the beta HCG value increase by less than ⅔rds it is most likely an ectopic pregnancy
○ if the value decreases it may be possible to manage the patient conservatively or with medical
management; discuss with your specialist referral hospital for further management
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Chapter 7
BLOOD TRANSFUSION
This chapter discusses the guidelines for ordering of blood and blood products, the process
of managing transfusions in obstetric heamorrhage, and managing adverse affects from
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In order to ensure the safety of blood transfusion, guidelines on ordering of blood and blood products should include:
• preparation of the patient
• correct identification and verification of the patient and the blood unit
• correct aseptic technique
• careful observation of the patient
REQUEST FOR BLOOD AND BLOOD PRODUCTS
• The form should be completed in full and must include the patient’s identification, the name of the hospital, ward
and area to which the blood needs to be delivered.
Specimen collection
• The doctor who orders blood is responsible for ensuring that the correct procedure is followed.
• Use a blood collection tube supplied or recommended by the blood bank.
• The label on the specimen tube must be completed in full at the patient’s bedside.
• Please ensure that the label with patient’s details is securely affixed to the blood specimen tube.
• The tube must be full of the blood specimen.
• Record the date and time the specimen was taken.
• Both the specimen and the ‘Request for Blood or Blood Components” form must be signed.
• If special services are required the doctor must discuss his/her request with the blood bank prior to submitting
the order, as some products are not stored at the blood bank and may need to be transported from the
processing centre.
• Details of the blood order should be noted in the patient’s records to ensure that the right blood is given to the
right patient and to prevent duplication of services.
ORDERING PRIORITIES
Un-crossmatched blood
Note: Un-crossmatched blood must not be used unless there is acute life-threatening haemorrhage.
• Use only in dire emergencies.

• No compatibility testing as no blood specimen is provided. Blood group confirmed.
• Un-crossmatched group O blood is:
○ issued within five to ten minutes from the Blood Bank
○ readily available from the Emergency Fridge. Be sure to complete the form, if this is not done the blood will
not be replaced and the next patient will be compromised
• This has a small risk that the patient may have an irregular antibody which may result in a haemolytic
transfusion reaction.
• All units must be recorded in the patient records.
Emergency crossmatch
• A blood specimen is provided to the blood bank.
• Tested for ABO group, Rh type, and antibodies.
• Blood is available within 20-30 minutes.
• Small risk that patient may have irregular antibodies.
• Weigh up the benefit against the risk when ordering blood on emergency.
Type and screen

• Tested for ABO and Rh groups.
• Screened for irregular antibodies and the doctor will be informed if there are irregular antibodies.
• Compatibility testing is done (blood is made available).
• Specimen will be retained for a period of 72 hours within which blood may be ordered.
Standard crossmatch
• Blood is fully crossmatched using standard compatibility testing methods.
• Blood is available in two hours from when the specimen arrives at blood bank.
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• Compatibility problems will result in delays.
• An after-hours service levy is charged if blood is ordered after 18h00.
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• Specimens will be retained for 72 hours and more blood can be ordered if the serum is enough.
Crossmatch and hold
• This is a special request that should be communicated to the blood bank staff.
• Blood is fully cross matched and is kept on standby.
• Retained in the blood bank for 24 hours.
• Blood is available immediately when patient needs it.
• A cancellation levy is charged per unit cancelled.
Blood on Returnable Basis (BRB)

(Blood conservation)
• Blood is issued in a BRB hamper, the hamper has two compartments. Blood is stored with ice packs and
temperature monitoring devices.
• The patient/hospital is only charged for blood transfused and credited for blood not used.
• These units can be returned to the blood bank within 12 hours of issue provided the hamper is still sealed.
• All units transfused must be recorded in the patient’s records.
GUIDELINES ON THE MANAGEMENT OF ACUTE MODERATE/SEVERE TRANSFUSION RELATED ADVERSE

EVENTS
Differential Diagnosis
• Haemolytic Transfusion Reaction
• Anaphylaxis
• Transfusion Related Acute Lung Injury (TRALI)
• Transfusion associated circulatory overload (TACO)
Management
• Stop the transfusion
• Change the transfusion set
• Check for identification errors
• Visual check for haemolysis
• Notify the blood bank
• Repeat patient’s ABO
• Send blood unit with giving set to the blood bank
• Bloods for FBC, Uand E and LFT
• Maintain intravascular volume with crystalloid/colloid solutions
• Strict input/output
• Refer the patient for specialist attention as management will need high/ICU care.
• If anaphylaxis is suspected give O2, adrenaline, and steroids
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Chapter 8
HYPERTENSIVE DISORDERS IN PREGNANCY

This chapter provides definitions and classifications of hypertension in pregnancy,
identifies those at risk, and provides advice for the treatment and management of various
hypertension disorders at different health facilities.
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Hypertensive disorders are one of the most common direct causes of maternal mortality and are responsible for sig-
nificant perinatal and maternal morbidity. These disorders include chronic hypertension, pre-eclampsia, eclampsia and
HELLP syndrome. Early detection and timely intervention is essential to prevent maternal and perinatal complications.
The exact cause of pre-eclampsia is unknown, therefore there is no effective method of treatment and the only known
cure is delivery of the baby. Early detection and treatment of the hypertension until foetal viability and timely delivery will
result in reducing death and morbidity from complications associated with pre-eclampsia.
DEFINITIONS
Hypertension
A diastolic blood pressure ≥ 90 mmHg but < 110 mmHg on two occasions, taken at least 2 hours apart, or a single diastolic measurement
of ≥ 110 mmHg
AND/OR
A systolic blood pressure ≥ 140 mmHg but <160 mmHg on two occasions, taken at least 2 hours apart, or a single systolic measurement of ≥ 160
mmHg. A raised systolic pressure is indicative of hypertension - even in the absence of a raised diastolic blood pressure.
Acute severe hypertension

A medical emergency and is defined as a systolic BP ≥ 160 mmHg and/or diastolic BP≥110 mmHg.
Significant proteinuria
The presence of 1+ or more proteinuria on a test strip (dipstick) in a clean catch urine specimen on 2 occasions, at least 2 hours apart. Test for
proteinuria in all antenatal patients using bed side tests.
CLASSIFICATION
Chronic Hypertension
Hypertension that is present before 20 weeks of gestation or if the woman was already taking antihypertensive medication before the pregnancy.
Gestational Hypertension
New onset of hypertension presenting only after 20 weeks of gestation without significant proteinuria.
Pre-eclampsia
Hypertension with significant proteinuria developing for the first time after 20 weeks of gestation.
Pre-eclampsia can also be superimposed on chronic hypertension - evidenced by the new onset of persistent proteinuria in a woman who had an
initial diagnosis of chronic hypertension.
• Mild to moderate pre-eclampsia: a diastolic BP of 90-109 mm Hg and/or systolic blood pressures of 140-159 mm Hg, with ≥1+ proteinuria;
and no organ dysfunction.
• Severe pre-eclampsia:
○ Acute severe hypertension (diastolic BP of ≥110 mmHg and/or systolic of greater than 160 mm Hg) with ≥1+ proteinuria
OR
○ Hypertension and/or proteinuria (any degree) with signs of organ dysfunction (platelets <100 000/µl; creatinine or liver enzymes (ALT)
more than double the normal values; or neurological signs like persistent headache, visual disturbances and dizziness)
Unclassified hypertension
Can be any of the above, but in a patient who only booked after 20 weeks so accurate classification difficult.
Significant proteinuria without hypertension

Can be chronic (prior- or HIV related kidney problems) or new (which may be the first sign of developing pre-eclampsia).
Imminent eclampsia
Symptoms and signs that characterise severe pre-eclamptic women, i.e. severe persistent headache, visual disturbances, epigastric pain, hyper-
reflexia, clonus, dizziness and fainting, or vomiting.
Eclampsia
Generalised tonic-clonic seizures after 20 weeks of pregnancy and within 7 days after delivery, associated with hypertension and proteinuria.
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HELLP syndrome
The presence of haemolysis, elevated liver enzymes and low platelets, almost always in association with hypertension and proteinuria
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Be aware that increases in BP levels of >30 mm Hg systolic and /or a rise in the diastolic of more than
15 mm Hg over BP values taken at the first booking visit may indicate the development of hypertension;
even if the blood pressure is not yet in the hypertensive range.
The presence of proteinuria without evidence of hypertension is a mandatory indication for a clean catch
urine specimen to be sent for investigation of urinary infection. In this circumstance the women should
return for antenatal care within a week.
Hypertension may be mild prior to delivery but rise significantly following delivery.
Low platelet counts may decrease further in the first 48-72 hours after delivery.
• Use correct cuff size (length of 1.5 times the circumference of the arm)
• Use obese cuff (15x33 cm) if the middle upper arm circumference is > 33 cm
• Patient may sit or lie on her side – never flat on her back!
• Cuff should be on the level of the heart during measurement
• Measure the diastolic blood pressure at the point where the sounds disappear (Korotkoff phase five). In patients
where the sounds do not disappear, use the point of muffling (Korotkoff phase four).
WOMEN AT RISK FOR THE DEVELOPMENT OF PRE-ECLAMPSIA
ANY pregnant women CAN develop pre-eclampsia. Those most susceptible are:
• primigravidae, in particular teenagers and elderly primigravidae
• women of age 35 years and above
• women with a previous pregnancy complicated by pre-eclampsia
• women with a previous abruptio placentae or intra-uterine death
• women with multiple pregnancies
• medical complications such as chronic hypertension, renal disorders, diabetes, connective tissue disorders or
antiphospholipid syndrome
• women who develop oedema in the mid trimester or have excessive weight gain
Women, their families and the community must be made aware of the dangers of hypertensive disorders in pregnancy
and specifically informed of the early symptoms and signs of the onset of pre-eclampsia.
Such information should be disseminated to communities by the primary health care nurse and by all maternity care
health professionals to pregnant women at every antenatal visit. This information can be disseminated through group
sessions and pictorial charts illustrating swollen feet, symptoms of persistent headaches, visual disturbances and
nausea and vomiting.
THE ROLE OF DISTRICT HOSPITALS IN MANAGING HYPERTENSIVE DISORDERS IN PREGNANCY
DISTRICT HOSPITALS
District hospitals should be able to manage women with gestational hypertension and women with mild to moderate
pre-eclampsia. Staff at district hospitals should stabilise and refer patients with acute severe hypertension, severe pre-
eclampsia, imminent eclampsia or eclampsia; to a specialist centre.
Patients can be stabilised by judiciously lowering high blood pressure, instituting emergency obstetric care and
Most health facilities have non-invasiveblood pressure (NBP) monitors for the measurement of blood
pressure levels. Ensure that these machines are calibrated at regular intervals (every 3 months).
A mercury BP machine should be kept in every facility for calibration.
Ensure that you have two cuff sizes-normal and obese.
transferring the patient (following telephonic contact) to a specialist hospital (management should follow ESMOE-
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EOST training packages).
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ACTIONS TO TAKE IF THERE IS A RISE IN BLOOD PRESSURE FROM A PREVIOUS VISIT
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If the patient still has normal blood pressure, but there was a rise in systolic or diastolic of 30 mmHg or 15 mmHg since
booking, ensure she is given an appointment to return in three to five days to repeat blood pressure measurement. Also,
ensure that the base hospital is contacted with respect to further management.
MEASURES TO PREVENT PRE-ECLAMPSIA
The following may help to reduce the chance of a women getting pre-eclampsia:
• Calcium supplementation to all pregnant women - 1g elemental calcium in divided doses daily, e.g. calcium
carbonate (168 mg) two tablets orally, three times daily with food. This is best taken four hours before or after iron
supplements.
• Low dose aspirin (75 mg; or a quarter of a standard tablet) taken daily from the 12th week of pregnancy until 34
weeks gestational age. Normally prescribed for those who have had a previous pregnancy loss due to severe
pre-eclampsia or abruptio placenta. These women must be managed at a regional hospital by a specialist or by
shared care with a district hospital.
HOW TO MANAGE HYPERTENSION IN PREGNANCY
GESTATIONAL HYPERTENSION
If gestational hypertension is diagnosed at a community clinic, the advice of an experienced doctor should be obtained
to establish if any immediate treatment and investigations are required and as to the timing of referral.
• check for proteinuria, oedema and increased weight gain
• ask again about family history of hypertension, history of hypertension in previous pregnancy, previous still-
births, neonatal deaths, bleeding in previous or index pregnancy and any symptoms of persistent headache
• take a dietary history and advise appropriately
• such patients should be referred to a district hospital within –three to five days
At the district hospital all patients should be re-assessed to confirm the diagnosis of gestational hypertension (NO
proteinuria), or to see if pre-eclampsia has developed in the meantime. If the diagnosis of gestational hypertension is
confirmed:
• Do an ultrasound assessment of the foetus in respect of gestational age or estimated foetal weight (if no
previous dating ultrasound available).
• Test for foetal well-being with an umbilical artery Doppler test (if available).
• If the baby is viable (≥28 weeks), an antenatal CTG should also be carried out and foetal movement charts
initiated (see figure 8.1, page 92).
• If the dipstick tests for proteinuria are doubtful, do a 24-hour protein collection to exclude pre-eclampsia.
Blood pressure in pregnancy should be controlled at values of 135-140 mmHg systolic and 85-90 mmHg diastolic.
Lowering the blood pressure further than this may compromise the baby. The patient may require antihypertensive
therapy but this should be based on the individual case.
• If needed, start anti-hypertensive treatment with methyldopa 250mg - 500 mg eight hourly; orally.
If the patient is less than 38 weeks, then outpatient management can occur at the high risk antenatal clinic on a
weekly basis and she should be seen by the same experienced doctor or midwife at each visit . Most of these
cases will have a good maternal and perinatal outcome but some may develop pre- eclampsia. Women with
gestational hypertension should be delivered once they reach 38 weeks of gestation. Delivery can be delayed
until 39 weeks if assessed by a specialist.
If a woman with gestational hypertension developes proteinuria, increasing weight gain or there are decreased foetal
movements, then she should be re-assessed and delivered.
MILD TO MODERATE PRE-ECLAMPSIA

Once labelled as stable mild to moderate pre-eclampsia:
• prescribe methyldopa 500 mg eight hourly and phone the district hospital for referral. Referral should be the
same day or the next day, especially if the patient is > 34 weeks gestation
• at the district hospital, all patients should have an ultrasound assessment of the foetus in respect of gestational
age or estimated foetal weight (if no previous dating ultrasound available)
• test for foetal well-being with an umbilical artery Doppler test (if available)
• if the baby is viable (≥ 28 weeks), an antenatal CTG should also be carried out and foetal movement charts
initiated
• confirm the diagnosis of mild to moderate pre-eclampsia with a 24 hour protein collection, except if there is
persistent proteinuria ≥1+ on the dipsticks
• with confirmed significant proteinuria (≥0.3 g/24 hour or persistent ≥1+), do a platelet count, serum creatinine
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and serum ALT and LDH
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If the patient remains stable, she should be managed as an in-patient until 36 completed weeks, when delivery (induction
of labour) is strongly advised.
• Do weekly platelet counts and twice daily CTGs.
• Remember to keep plotting the growth of the baby on the antenatal card every two weeks.
• Outpatient management can be individualised for the very reliable patient who lives close by.
Contact a specialist health facility for further management if any acute severe hypertension or imminent signs of
eclampsia or organ dysfunction develop during her stay. These symptoms now indicate a diagnosis of severe pre-
eclampsia.
SEVERE PRE-ECLAMPSIA OR IMMINENT ECLAMPSIA

The patient should be stabilised and have immediate priority transfer to a specialist hospital.
• Insert foley catheter and plot urine output.
• Insert an IV line and give RESTRICTED IV fluid – use a 200 mL Ringers lactate ensuring against fluid overload.
Give 80 mL per hour.
• Initiate magnesium sulphate (MgS04) prophylaxis against the development of seizures. Dilute four ampoules
(four gram) in 200 mL Ringer Lactate and infuse over 20 minutes. If transfer will take longer than four hours,
also give fivr g MgS04 deep intramuscularly in each buttock (a total dose of 14 g). For quick transfer (specialist
centre close by) the four g IV is sufficient.
• Give 500mg alpha methyl dopa orally stat.
• If there is acute severe hypertension (blood pressure is ≥160 mm systolic or ≥110 mm diastolic) give nifedipine
10 mg orally to swallow (not bucally, not sublingually )).
• Repeat blood pressure measurement every half hourly until the ambulance arrives; a nurse should stay with the
patient. If the blood pressure is still ≥160 mm systolic or ≥110 mm diastolic 30 minutes after nifedipine, a second
dose of nifedipine can be given.
• Inform EMS and the specialist hospital of the urgency for referral. Inform the clinic manager of the case and any
transport difficulties.
• Ensure that the patient is accompanied by an experienced nurse or well-trained paramedic to ensure that the
MgS04 regimen is continued, that the patient is kept on her side and that complete records accompanies the
patient and are handed over to the receiving health professional.
MANAGEMENT OF SEVERE PRE-ECLAMPSIA/IMMINENT ECLAMPSIA IN A DISTRICT HOSPITAL
All efforts should be made to transfer to specialist care immediately, as the mother or baby may need high care or ICU
during the course of the disease. If transfer is not possible (e.g. mother very close to delivery) manage as follows:
• blood pressure levels must be kept below 160 mmHg systolic and 110 mmHg diastolic with the use of nifedipine
10 mg orally
• if there is still acute severe hypertension after three doses of nifedipine, the patient needs intravenous labetalol
to control her blood pressure. This should preferably take place within a high care setting with invasive blood
pressure monitoring. The dose of labetolol is 20 mg IV
• if there is still acute severe hypertension after 10 minutes give a further 40 mg labetolol IV
• be aware of fluid balance and check the pulse rate, respiratory rate, and chest examination for signs of
pulmonary oedema and urine output at each observation period
• be aware of a pre-eclamptic patient with respiratory rate >24/minute- examine the lungs carefully for pulmonary
oedema
• continue observations following delivery in a high care area or designate a bed in which regular observations
are done (blood pressure, pulse rate, respiratory rate, chest examination and fluid balance – use a colour coded
observation chart/early warning chart). Observations should be done:
○ half hourly for two hours
○ then hourly for four hours
○ then two hourly for eight hours
○ then fourhourly
• MgSO4 should be continued for up to 24 hours after delivery.
• the best mode of delivery for severe pre-eclampsia and eclampsia is vaginally and not a caesarean section.
Anaesthesia for severe pre-eclampsia is complicated and should best be done by a specialist anaesthetist. If
the patient is in labour or has a favourable cervix, there is no contraindication for vaginal delivery. Always seek
specialist advice.
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On admission of women with pre-eclampsia, ensure that a full history is obtained and a full clinical
assessment is done. Special attention should be given to:
• Symptoms of imminent eclampsia
• Vaginal bleeding
• Severity of oedema
• Pallor and jaundice
• Heart and lung examination
• Precise measurement of the BP, to the nearest 2 mmHg
• A repeat BP measurement after 20 minutes
• Uterine tenderness, irritability, fetal size and liquor volume
• Assessment of the cervix for induction of labour
STEP-WISE MANAGEMENT OF ECLAMPSIA
• This is an emergency; shout for help and start with immediate stabilisation. The mother now gets preference.
• Turn patient on her side, extend her neck, suction the airways and insert an oral airway, if appropriate.
• Give 02 by facemask.
• Initiate MgS04. Give a loading dose of four g MgS04 diluted in 200 mL Ringer’s lactate or saline over 20 minutes
to arrest the seizure and to prevent further seizures.
• Follow this with maintenance: five gram MgS04 intramuscularly, deep into each buttock. Repeat with five g
every four hours IM into alternative buttocks. Alternatively, if infusion pumps are available put four grams in 200
mL fluid and infuse at 50 mL/hour (instead of the IM doses) for maintenance.
• Lower high blood pressure with one gram methyldopa + 500 mg eight hourly orally. If systolic or diastolic >
160/110 mmHg, use Nifedipine as above.
• Occasionally the patient may be restless; in this instance give one mg of clonezapam (Rivotril©) IVI slowly. Do
not use diazepam.
• Draw blood for haemoglobin, platelet count, creatinine, ALT and LDH.
• Assess the foetal condition ONLY once the mother is completely stable AND the platelet count is known. Rule
out abruptio placenta or intra-uterine growth restriction. Do a CTG only if the baby is viable.
• Assess whether the patient is in labour, as women with eclampsia often go into spontaneous labour. In these
circumstances, if vaginal delivery is not contraindicated, allow spontaneous vaginal delivery before transfer.
However, ensure that there is no excessive bearing down and do not use syntometrine or ergometrine. Instead,
use oxytocin 10 units intramuscularly for the active delivery of the placenta and for prevention of postpartum
haemorrhage.
• Note that irrespective of an eclamptic’s condition, advice must be obtained from an experienced obstetrician,
and detailed notes made. If the patient is not in labour, and once the mother is stable, she must be transferred
to a specialist level of care.
• Assess the general condition of the patient using the AVPU scale (whether the patient is Alert, responds to
Verbal questions, responds to Pain, or is Unresponsive). The Glasgow Coma Scale is an alternative.
• The norm for patients with acute severe hypertension, imminent eclampsia or eclampsia is that their
management should be at a specialist health care facility as soon as they are stable enough for transfer.
Anaesthesia in woman with eclampsia is extremely complicated and should preferably be done by a specialist.
POSTPARTUM AND POSTNATAL CARE
• Women who develop threatening signs or eclampsia for the first time after delivery need referral to specialist
care after stabilisation. Use MgS04 as above.
• Patients with hypertension during pregnancy need to stay in hospital after delivery until the blood pressure is
well controlled (< 150/100 mmHg).
• Use nifedipine 10 mg orally as needed to manage acute severe hypertensive spikes.
Management of the asymptomatic patient who had isolated high blood pressures during labour only (no
hypertension in the antenatal period and no significant proteinuria)
• Observe post-partum until the blood pressure settles (usually one to three days).
• If diastolic blood pressure repeatedly raised ≥110 mmHg OR the systolic blood pressure rises to >160 mmHg
(treated with 10 mg doses of nifedipine), start on maintenance anti-hypertensive medication.
• If the systolic blood pressure is 140-150 mmHg and/or the diastolic blood pressure is 90-100 mmHg, treatment
is not necessary. Observe patient for 24-48 hours and follow up at a district health service postnatal clinic within
three days.
• The patient should return for care if she experiences persistent dizziness or headaches.
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• Preferably, stop the methyldopa after delivery (as it can exacerbate post-partum depression) and switch to other
anti-hypertensive medication if needed.
• Confirm that the blood pressure is stable for 24-hours before discharge.
• Follow up at a district health service post-partum clinic within three days and again at six weeks post-partum, to
evaluate the need for continuation of medication.
• If maintenance therapy is needed, provide a prescription for four weeks with discharge so that the client is
without medication for two weeks when followed up at the six weeks visit. A good assessment can then be
made as to whether she will need further workup for hypertension and chronic medication.
• If she was discharged on more than one drug to control the blood pressure, rather do a step-wise withdrawal of
one drug at a time with more regular follow up, preferably at a specialist high-risk clinic.
• The patient should return for care if she experiences persistent dizziness or headaches.
Patients with chronic hypertension

• Can be changed to the drugs they used before pregnancy (if it is safe to use during lactation) and discharged as
soon as they are stable.
• They can be followed up after three days and again after 6 weeks at the district health service postnatal clinic.
Patients with severe pre-eclampsia during pregnancy

• Follow the advice from the specialist centre (if transfer was not possible before delivery).
• The patient should be managed with anti-hypertensive medication after delivery and kept in hospital until blood
pressure is controlled for 48-hours and all the biochemistry / organ systems are back to normal.
• Follow up three days after discharge at the nearest clinic and again at six weeks postpartum at a high-risk
postnatal clinic, to evaluate the need for continuation of medication.
• If there is good control with one drug only, provide a prescription for four weeks with discharge, so that the client
is without medication for two weeks when followed up at the six weeks visit. A good assessment can then be
made as to whether she will need further workup for hypertension and chronic medication.
• If she was discharged on more than one drug to control the blood pressure, rather do a step-wise withdrawal of
one drug at a time with more regular follow up at a high-risk clinic.
• The patient should return for care immediately if she experiences persistent dizziness or headaches.
CHOICE OF DRUGS FOR POST-PARTUM HYPERTENSION
• A general approach would be to use the cheapest effective drug available at all levels of care and to adhere
to the guidelines on hypertension outside of pregnancy, as the clients will be managed after the puerperium
according to those guidelines.
• A first choice would thus be an ACE inhibitor (enalapril) at a dose of 5 mg in the morning, can be increased to
20 mg daily. (If the patient’s renal function is within normal limits.)
• • When a second drug is needed, add a calcium channel blocker (amlodipine) 5 mg daily and increase to 10 mg
daily when needed.
• When a third drug is needed, use a beta blocker (atenolol) 50 mg daily. Can be increased to 100 mg daily if
needed.
• Hydrochlorothiazide can be started as a first line drug in cases of chronic hypertension (12.5 mg daily, increase
to 25 mg daily when needed).
• As with the prescription of any drug, check for contra-indications and possible drug interactions before
prescription.
Most frequent causes of maternal deaths associated with hypertensive disorders

• Cerebral haemorrhage and severe cerebral oedema usually due to acute severe uncontrolled high blood
pressure. Therefore lowering of very high blood pressure requires drugs which act fairly rapidly
○ Lower high blood pressure using Nifedipine or Labetalol in such circumstances. Methyldopa should be
used at the same time but its onset is variable and may take 12 to 24 hours to act
○ Note that Magnesium Sulphate is not antihypertensive, therefore rapid acting agents must be used to lower
very high blood pressure over two hours to stabilise prior to transfer.
• Pulmonary oedema which may be due to iatrogenic fluid overload, therefore do not overload patients with IV
fluids and closely monitor urine output and fluid intake.
• Be aware of abruptio placentae and liver rupture in cases of severe pre-eclampsia.
• Renal impairment and acute renal failure may occur following delivery therefore fluid balance monitoring is
essential.
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Figure 8.1: Fetal movement chart

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Date Time started Movements in first NB Movements in NB

hour second hour
If less than 4 If less than 4
movements in the movements in the
first hour go on to second hour please
the second hour and go to your clinic for
count again a further test
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Chapter 9
PROBLEMS IN PREGNANCY

This chapter discusses common problems in pregnancy, including: Intrauterine growth
restriction, antepartum haemorrhage, multiple pregnancies, breech presentation and
transverse lie, preterm labour, pre-labour rupture of the membranes, chorioamnionitis,
prolonged pregnancy, vaginal birth after previous caesarean section (VBAC), rhesus
incompatibility and poor obstetric history.
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INTRAUTERINE GROWTH RESTRICTION
Intrauterine growth restriction (IUGR) refers to the failure of a fetus to achieve its growth potential. IUGR can be classified
into two main groups:
• symmetric - the head and body both show growth failure. This may result from genetic or chromosomal defects,
intrauterine infection or exposure to teratogenic substances. Liquor volume is usually normal.
• asymmetric - the head grows, but the body shows growth failure. This is usually associated with placental
insufficiency. This may result from pre-eclampsia or vascular disease (as in diabetes or lupus). Liquor volume
may be reduced.
Some fetuses may appear symmetrically growth impaired, but are normal small babies, or may be suspected to be small
because of wrong pregnancy dates.
SCREENING
Identifying pregnant women at risk
• hypertensive disorders
• history of previous IUGR or low birth weight babies
• history of previous abruptio placentae
• substance abuse - smoking, alcohol, cocaine
• vascular disease, e.g. lupus
• previous history of abruptio placentae
• poor nutrition/underweight
• chronic infections including sexually transmitted infections
Serial measurement of symphysis-fundal height (SFH)

A measurement less than the 10th centile for gestational age (as noted on the antenatal SFH graph), or failure of SFH
to increase on serial measurements, should raise suspicion of IUGR, and the mother should be referred for ultrasound
assessment of the fetus.
Palpation
Features that suggest IUGR include palpation of a relatively large hard fetal head with a small body, engagement of
the head before 37 weeks, reduced liquor volume, and an irritable uterus before 37 weeks. Such findings should lead
to referral for ultrasound to exclude IUGR.
DIAGNOSIS
Ultrasound scanning, including Doppler flow studies, is used to make a diagnosis. If ultrasound facilities are not
available, clinical assessment must be used, or the mother must be referred to a specialist health facility.
If symmetric IUGR is diagnosed:

• Exclude a cause, especially chromosomal and congenital defect, or congenital infection.
• Delivery is indicated at ≥37 weeks.
• Before 37 weeks, evaluate the fetus (by ultrasound) for abnormalities
○ If there are no fetal abnormalities, the mother can go home with a fetal movement chart (see figure 8.1,
page 92) and return for reassessment after 2 weeks
○ If an abnormality is found, manage accordingly
If asymmetric IUGR is diagnosed:

• identify the cause and manage accordingly. There is a high risk for sudden IUD and mothers should preferably
be managed at specialist level
• delivery is indicated at ≥34 weeks
• if dates or the diagnosis are uncertain, perform amniocentesis for foetal lung maturity testing (shake test or
laboratory tests)
• at less than 34 weeks, admit to hospital for daily foetal movement counts (see figure 8.1, page 92) and CTGs at
least twice weekly
• repeat ultrasound assessment after two weeks. Delivery is indicated if there is any evidence of foetal distress
DELIVERY
During induction of labour for IUGR, monitor the foetus closely by CTG, because of a high risk of foetal distress.
Caesarean section is recommended for delivery of small babies with severe asymmetric IUGR. If the estimated foetal
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weight is <1500 g, transfer the mother to a specialist hospital for delivery.
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ANTEPARTUM HAEMORRHAGE
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Antepartum haemorrhage (APH) is defined as bleeding from the genital tract from 20 weeks of pregnancy up to delivery
of the baby.
CAUSES
• Placental - abruptio placentae, placenta praevia, vasa praevia.
• Non-placental - vaginal and cervical lesions including cancer, cervical infections, trauma and decidual bleeding.
• Unknown - APH of unknown origin.
Note: All patients presenting with APH must be regarded as obstetric emergencies until properly
assessed. Transfer urgently to hospital.
EMERGENCY MANAGEMENT
At a clinic or community health centre
• Start an intravenous infusion of Ringer-Lactate solution.
• If the mother is in shock, resuscitate with one to two L of Ringer-Lactate.
• Do not do a digital vaginal examination, unless placenta praevia has been excluded by a previous ultrasound
scan.
• Transfer urgently from a clinic or community health centre to a specialist facility where 24 hour caesarean
section services and adequate blood supply is available.
At the hospital
Re-evaluate the patient. If bleeding is mild
• Take blood for FBC and cross match.
• Do an ultrasound scan to help with the diagnosis.
• If placenta praevia is found, manage accordingly.
• If no placenta praevia, exclude a minor abruption by doing a full clinical examination and CTG.
○ Frequent uterine contractions (>5/10 minutes) suggests abruptio placentae
○ If there is fetal distress and the baby is viable, deliver the woman by an emergency caesarean section
• Do a speculum examination to exclude a local cause.
• Further management depends on the cause.
If bleeding is severe
Make a clinical diagnosis of whether abruptio or placenta praevia and manage according to the cause.
Figure 9.1: Distinction between abruptio placentae and placenta praevia

Abruptio placentae Placenta praevia
Patient Often hypertensive.
History of abdominal trauma Often previous caesarean section.
Symptoms Pain almost always present. Fetal movements Usually painless. Fetal movements usually
may be absent or reduced. normal.
Abdominal examination Hard, tender uterus, large for expected dates. Soft, nontender uterus, often with mal-
presentation or high presenting part.
Bleeding Dark blood with clots, at times no external Bright red blood.
bleeding visible.
Ultrasound Fetus may be dead, placenta normally situat- Placenta implanted close to or over the cervix.
ed. Retroplacental clot may be seen.
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• Continue resuscitation.
• Check Hb level and cross match.
• If less than 10 g/dL, commence blood transfusion and transfer urgently to a specialist hospital.
At the Specialist hospital

• Obtain consent for caesarean delivery n and hysterectomy (should hysterectomy becomes necessary during
the caesarean delivery).
• If the bleeding is significant, perform a caesarean delivery (supervised or done by an experienced doctor or
specialist).
• If less than 36 weeks, and bleeding subsides, manage conservatively – keep in hospital, observe vital signs and
give steroids and antibiotics. Deliver electively at 36 weeks.
MANAGEMENT OF ABRUPTIO PLACENTAE

Abruptio placentae is strongly associated with pre-eclampsia: the blood pressure may be low due to the presence of
clinical shock but hypertension may manifest as soon as the patient is resuscitated. Proteinuria may be an indicator of
underlying pre-eclampsia with abruptio placentae.
If the foetus is alive and viable

• If the foetal heart rate >100/minute as recorded on CTG, perform emergency caesarean delivery, unless
delivery is imminent (cervix ≥9 cm dilated).
• For a non-viable baby, rupture the membranes and augment labour with oxytocin. Monitor blood loss carefully.
If the foetus is dead

• A dead foetusfoetus with abruptio placentae signifies massive blood loss. Resuscitate and transfer urgently to
a specialist hospital. Rupture membranes as soon as possible, even if the cervix is unfavourable; before the
ambulance arrives.
If transfer to a specialist hospital is not possible, manage as follows:

• Aim to deliver vaginally within eighthours.
• Take blood for cross-match, FBC, INR, PTT, and urea and creatinine.
• Blood transfusion (two to four units) is usually necessary, with one-two units of fresh frozen plasma.
• Insert a central venous pressure (CVP) line through a cubital vein, if feasible.
• Insert an indwelling urinary catheter and monitor hourly urine output.
• Give fluids to maintain a systolic BP ≥100 mmHg, or a CVP of six cm H20.
• If there is no progress of labour within one to two hours after AROM, augment with oxytocin if not
contraindicated.
• Give analgesia using morphine five mg IM four hourly if necessary.
• Caesarean section is indicated if:
○ there is lack of progress despite oxytocin augmentation, life-threatening haemorrhage, ongoing DIC, or
severe oliguria
○ the patient is not near delivery after eight hours
This is a high-risk procedure and must preferably be done in a specialist institution.
Following delivery, there is a significant risk of complications

• Active management of the third stage is mandatory.
• In addition, add oxytocin 20 U in one L Ringer-Lactate immediately after delivery and observe for bleeding. Do
not remove the IV line for at least 12 hours.
• Monitor vital signs hourly, and observe for postpartum haemorrhage for at least twelve hours.
• Check Hb, platelet count, urea and creatinine on the day after delivery.
• Be aware of complications (DIC, renal failure, pulmonary oedema) and take the necessary precautions.
• Provide psychological support and advice about contraception and future pregnancies.
If delivery occurred at a District hospital, transfer to a Specialist Facility if:

• the woman also has severe pre-eclampsia or eclampsia.
• there is evidence of DIC - spontaneous bleeding from the mouth or puncture sites.
• urine output is less than 30 mL/hour for more than fourhours.
• there is pulmonary oedema.
• there is evidence of acute renal failure - increasing urea and creatinine levels.
• there is severe thrombocytopenia (<50,000/mm3).
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This is a common problem in obstetrics, where there is no evidence of abruptio placentae, placenta praevia, or
cervical or vaginal (local) causes.
• admit the mother to hospital to exclude an abruptio that may not be clinically apparent
• do six hourly CTG until the bleeding stops; then daily CTG
• observe for symptoms and signs of abruptio placentae
• observe for any evidence of chorioamnionitis
• discharge from hospital 24-48 hours after bleeding has stopped
• assess the cervix before discharge to excluded imminent preterm labour
• continue antenatal care at hospital, with attention to foetal growth and foetal movements
See figure 9.2 below for the algorithm for the diagnosis and management of antepartum haemorrhage.
Figure 9.2 : Algorithm for the diagnosis and management of Antepartum Haemorrhage (APH)
Antepartum Haemorrhage
Ringer-Lactate IV infusion
Assess blood loss
Check foetal heart
Massive haemorrhage or No massive haemorrhage or

foetal distress foetal distress
Resuscitation blood transfusion Abdominal examination

Urgent caesarean section or delivery Ultrasound examination
Placenta praevia Abruptio placentae
No cause found
Algorithm for the

diagnosis and
management of
Antepartum
Haemorrhage (APH) Speculum examination
APH of unknown origin Cervical or vaginal

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MULTIPLE PREGNANCY
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Multiple pregnancies are diagnosed most accurately by ultrasound examination. Where this is not routinely offered to
all pregnant women, multiple pregnancy needs to be suspected on history and clinical examination. A family history of
multiple pregnancies and history of ovulation induction should raise suspicion. Pregnancies with the following signs
need referral for ultrasound assessment:
• exaggerated symptoms of pregnancy

• symphysis-fundal height >90th centile for gestational age (if no previous ultrasound)
• an unusually wide and round uterus
• increased liquor volume
• more than two foetal poles felt
• head feels smaller than expected for the uterine size
ANTENATAL MANAGEMENT
• All antenatal visits must take place at a hospital with level two sonography (see chapter 14); preferably at
specialist hospital. Refer twins as early as possible to make a correct ultrasound diagnosis of chorionicity.
Monochorionic pregnancies must be referred to a foetal medicine unit for further follow up.
• Warn the mother of possible complications: preterm labour, anaemia, hypertension and general discomfort.
• Scheduled visits are every four weeks to 28 weeks, then every two weeks to 36 weeks, and then weekly to
delivery.
• Give ferrous sulphate tablets 200 mg orally twice daily and folic acid five mg orally daily to prevent anaemia.
• Ultrasound scan is done every four weeks from 28 weeks to follow foetal growth.
• Assess the cervix at each visit.
DELIVERY
All multiple pregnancies should be delivered in a hospital with ultrasound, 24 hour caesarean section and 24 hour
neonatal facilities (preferably at specialist level).
Indications for elective caesarean delivery

• triplets (or higher order pregnancy)
• intrauterine growth restriction
• first twin breech or transverse lie after 37 weeks
• previous caesarean section
Principles of labour and delivery

• treat preterm labour as for singleton pregnancies
• induction of labour is not contraindicated
• use a partogram for observing labour progress
• monitor both foetusfoetuses during labour with CTG
Delivery
• The most experienced doctor/midwife in the unit must be present at (or conduct) the delivery, as well as an
additional person to do foetal resuscitation.
• Deliver the first baby as for a singleton pregnancy, clamp the cord but do not administer IM oxytocin or attempt
to deliver the placenta now.
• As soon as the first baby is delivered, check the foetal heart of the second foetusfoetus. If there is foetal
distress, and delivery is not imminent, do a caesarean section.
• If there is no foetal distress, check the lie; and if the baby is not in a longitudinal lie, do external version to a
longitudinal lie- whether breech or cephalic does not matter, turn whichever way is quickest and easiest to
obtain a longitudinal lie. Administer salbutamol (see suppression of labour regime) to facilitate the version, if
needed.
• Await the return of contractions and the descent of the presenting part into the pelvis. Do not rupture the
membranes of the second baby before the presenting part is on the perineum.
• If there are poor or no contractions, and no foetal distress, oxytocin may be used for labour augmentation. Put
10-20 units oxytocin in one litre ringer’s lactate and titrate until there are three strong contractions.
• Wait until the presenting part has descended to the level of the ischial spines or below, then rupture the
membranes.
• After excluding a possible third baby, do active management of the third stage and deliver the placentas.
• In addition, add 20 units of oxytocin to one litre Ringer-Lactate and infuse at 120-240 mL/hour, to prevent
postpartum haemorrhage.
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BREECH PRESENTATION AND TRANSVERSE LIE

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Clinics and community health centres should refer a suspected breech presentation or transverse lie to hospital at 36
weeks gestation.
EXTERNAL CEPHALIC VERSION

External cephalic version (ECV) should be attempted on all normal singleton breech presentations from 36 weeks
gestation, with the following precautions:
• exclude contraindications, i.e. hypertension, scarred uterus, antepartum haemorrhage, or ruptured membranes
• only perform ECV in a hospital
• give Anti-D 100 micrograms IM to all rhesus-negative mothers after the procedure
• do not anaesthetise or sedate the mother
• use Salbutamol IV to relax the uterus if necessary
• never use excessive force
• perform CTG tracings before and after ECV, whether successful or not
• observe the mother for a few hours after the procedure for complications, i.e. labour, rupture of membranes,
antepartum haemorrhage
LABOUR AND DELIVERY

Management of a woman with breech presentation in early labour
• transfer the mother from a clinic or community health centre to hospital
• exclude foetal abnormality or multiple pregnancies by ultrasound if necessary
• attempt external cephalic version if there are no contraindications
• estimate foetal weight and pelvic adequacy
• determine cervical dilatation and station of presenting part
• perform caesarean section unless suitable for vaginal delivery (see below)
Vaginal breech delivery

Elective caesarean delivery is the safest method of delivery for a primigravid woman with a breech presentation, if ECV
is not successful. This should be done after 39 weeks, but before she goes into labour. Multigravid woman may prefer
vaginal breech delivery, and some may arrive at hospital or at a community health centre in advanced labour. Vaginal
breech delivery must be personally supervised by the most experienced person available.
Breech presentation suitable for vaginal delivery

• Mother understands and accepts vaginal delivery
• operator experienced and confident with vaginal breech delivery
• no signs of pelvic contraction on clinical assessment
• estimated foetal weight less than 3.5 kg
• frank or complete breech
• presenting part at or below the level of ischial spines
• labour progress ≥1 cm per hour
Dead and grossly abnormal babies, and those with estimated weight <1 kg should preferably be delivered vaginally.
Technique of delivery
• Put the mother in lithotomy position.
• Cut an episiotomy after infiltration of the perineum with local anaesthetic.
• Encourage spontaneous breech delivery and only assist in keeping the foetal back facing upwards.
• For extended knees, assist by flexing at the knees and gently delivering each leg.
• After delivery of the trunk, allow the breech to hang, pull the cord down and cover the delivered parts with a
cloth.
• As the scapulae appear, be ready to assist with delivery of the arms.
• Deliver the arms if necessary by running your fingers from the foetal back over the shoulder and sweeping the
arms down in front of the chest, and then out.
• The neck will deliver up to the nape.
• Deliver the head by laying the foetusfoetus over the right forearm (right-handed midwife or doctor) and inserting
the right middle finger into the baby’s mouth, with the index and ring fingers supporting the cheek, to flex the
head.
• Simultaneously, the left hand exerts suprapubic pressure to flex the head (Wigand-Martin method) or pushes
directly onto the occiput to assist flexion (Mauriceau-Smellie-Veit method).
• Ease the baby out, with gentle traction, and continuous flexion as described.
• Should the foetal back face downwards after delivery of the arms, the head may be trapped. The best chance of
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delivery is to swing the foetusfoetus anteriorly over the maternal abdomen to flex the head.
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Do an ultrasound scan to exclude a cause such as placenta praevia, congenital abnormalities, or multiple pregnancy.
External version may be attempted from 37 weeks’ gestation. Caesarean delivery is required if version fails to achieve
a stable longitudinal lie.
Any woman presenting in labour with a transverse lie needs delivery by caesarean delivery by a specialist or experienced
doctor. A classical or low vertical uterine incision should be considered.
PRETERM LABOUR
This is defined as the onset of labour after the gestation of ≥ 24 w0d and before 37 completed weeks (37w0d) of
pregnancy. Management depends on the gestational age and/or estimated foetal weight (by palpation or ultrasound).
The onset of labour is determined by:
• documented regular uterine contractions (at least one every 10 min), with
• documented cervical changes: Dilation of >2 cm at internal os and cervix length ≤ 1 cm, or
• documented rupture of membranes
Gestational age ≥ 34 weeks (or estimated fetal weight ≥ 2 kg if gestation unknown)

• look for underlying causes of preterm labour, e.g. chorioamnionitis or other infections (with fever and
tachycardia), or abruptio placentae
• manage labour as for term pregnancies. There is no need to transfer from a clinic or community health centre to
a hospital
Gestational age 26-33 weeks (or estimated fetal weight 800 g – 1999 g if gestation unknown)
• Transfer from a clinic or community health centre to a hospital*. Give tocolysis (single dose Nifedipine or IV
salbutamol- see below) to suppress contractions during transfer.
• Refer to Appendix 2 for guide on giving of antenatal steroids.
At the hospital
• Look for a possible cause for the preterm labour- e.g. vaginal discharge or UTI; do urine MCS (before
commencement of antibiotics).
• Do tracing CTG.
• If there is evidence of abruptio placentae or chorioamnionitis, allow labour to proceed under close foetal
monitoring with CTG, or consider caesarean section.
• If cervix ≥6 cm dilated and there are strong contractions, allow labour to proceed (but do not augment labour).
Deliver the baby in a slow and gentle fashion, with an episiotomy if the perineum is very tight.
• If cervix <6 cm dilated, continue tocolysis. Try and continue suppression of labour until 48 hours have passed
since the first dose of β-methasone.
• Only give antibiotics in selected cases where there is evidence of sepsis or a high index of suspicion that
sepsis is the underlying cause of the preterm labour (e.g.ampicillin 2 g IV followed by 1 g IV 6 hourly and
metronidazole 400 mg orally three times daily for four days or azithromycin one gram daily and metronidazole
400mg orally three times daily for four days).
• Give steroids (preferably betamethasone 12 mg IM; repeated after 24 hours, or dexamethasone eight miligram
eighthourly for 24 hours (total dose of 24mg).
• The patient can be discharged if she was successfully suppressed [i.e. no contractions for 48 hours]. Repeat
cervical assessment before discharge. Make good notes in the Maternity Case record and change her risk
category to “high risk”.
• Follow up in one week at a high-risk clinic; continue follow up until 34 weeks. Reassess patient for follow up at a
CHC/MOU from 34 weeks onwards.
If the estimated fetal weight is <1500 g, transfer the mother to a hospital with neonatal intensive care facilities
(specialist hospital).
Gestational age <26 weeks or estimated fetal weight <900 g

• Transfer from a clinic or community health centre to hospital.
• Allow labour to proceed.
If the baby is born alive, evaluate for viability and administer comfort care if baby not vigourous (see steroid guideline
in appendix 2)ocolysis regimen
1. Calcium channel blocker: Short acting Nifedipine (Adalat®) to be used as 1st line treatment.
• dose: 30 mg loading dose orally (do not chew or take sublingually) and 20 mg three hours later. If there are still
contractions, continue with 20 mg six hourly per os for 48 hours.
• contraindications: All cardiac diseases, hypotension and hypertensive diseases.
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2. Prostaglandin synthetase inhibitor – Indomethacin (Indocid®)
• to be used as second line treatment after Nifedipine, if initial tocolysis was not successful.
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dose: 100 mg rectal suppository 12 hourly for three doses.
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• contraindications: pre-existing gastrointestinal ulcers/lesions, known allergy to NSAIDS, significant renal or
hepatic impairment, sure gestation of ≥ 32w0d (If unsure gestation an EFW ≥ 1500 g).
3. If at this stage tocolysis is not effective in stopping the contractions, the use of a beta two stimulant (Salbutamol) as
an adjunct can be considered.
• Salbutamol (Ventolin®) Dose: 250 µg (½ of 500 µg ampoule diluted in 20 mL saline) slowly IV as a single dose
as soon as possible
• can continue with an infusion: two miligrams (4 ampoules) in 200 mL saline at one mililitre/minute and increase
every 10 minutes by one mililitre/minute until maximum of four mililitre/minute or pulse >120 bpm
• contraindications include cardiac arrhythmias, maternal tachycardia (pulse > 110 bpm before treatment), all
underlying cardiac and diabetic disease
4. Contraindications for Tocolysis
• mother does not consent to suppression
• pathological or suspicious fetal heart rate pattern
• lethal fetal anomaly
• intra uterine fetal death
• suspected chorioamnionitis (clinical signs of infection)
• severe hypertensive conditions in pregnancy
• abruptio Placentae
• severe IUGR
5. There is no benefit in continuing suppression for longer than 48 hours.
PRELABOUR RUPTURE OF THE MEMBRANES
This is a rupture of the membranes before the onset of labour. The diagnosis must be confirmed by visual inspection,
by speculum examination, pH testing of vaginal fluid or, if necessary, liquor volume assessment on ultrasound. Digital
vaginal examination must be avoided. Management depends on gestational age and/or estimated foetal weight (by
palpation or ultrasound).
Gestational age ≥34 weeks or estimated fetal weight ≥2 kg

• transfer from a clinic or community health centre to hospital
• allow labour to proceed
• if the mother is not in labour within 12hours, start antibitoitics (ampicillin and metronidazole as in EML) and refer
for induction of labour with oxytocin or with oral misoprostol
• do not perform digital vaginal examinations until the patient has at least two hours of strong contractions and
the head has engaged
Gestational age 24-33 weeks or estimated fetal weight 600 g –1 999* g

• do not do digital vaginal examination as this may contribute to foetal infection.
• give azithromycin once daily for 10 days or until delivery
• give steroids (preferably betamethasone 12 mg IM repeated after 24 hours, or dexamethasone four miligrams
IM eight hourly for six doses)
• give tocolysis if contractions start in the first 24 hours after admission
• observe temperature, maternal heart rate, foetal heart rate, and pad checks six hourly
• do abdominal examination for tenderness; and CTG daily
• induce labour at 34 weeks (or EFW of 2 kg if unsure), or if there are any signs of chorioamnionitis
• during labour, give ampicillin 2 g IV, followed by 1 g IV six hourly until birth (to prevent beta haemolytic
streptococcal infection)
If delivery is expected for a baby of weight <1500 g, transfer the mother to a hospital with a neonatal intensive
care unit, (level 2 or level 3).
Gestational age <24 weeks or estimated fetal weight <600 g

• ensure that the membranes have definitely ruptured (reduced liquor volume on ultrasound)
• induce labour with oxytocin 10-20 units in 1L Ringer-lactate at 120 mL/hr, after counselling the mother
appropriately
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See figure 9.3 below for the algorithm for the management of preterm labour and prelabour rupture of the membranes.
Prelabour rupture of the

membrane
Gestation ≥ 34 weeks Gestation 24-33 weeks Gestation < 24 weeks

Foetus ≥ 2 000 g Foetus 600-1 999 g Foetus < 600 g
≥ 2 kg
Antibiotics induce labour after Antibiotics induce labour after

12-24 hours counseling
Evidence of No evidence of
chorioamnionitis chorioamnionitis
Antibiotics Betamethasone Antibiotics Betamethasone

Induce labour Monitor for signs of infection
Induce labour at 34 weeks
Algorithm for the management of prelabour rupture of the membranes
CHORIOAMNIONITIS
This infection (previously called intrauterine infection) may be associated with preterm labour, pre-labour or prolonged
rupture of membranes, intrauterine death or antepartum haemorrhage of unknown origin.
Signs of chorioamnionitis include:
• temperature ≥38 degrees celsius
• maternal heart rate ≥100/minute
• uterine tenderness and/or irritability
• foetal heart rate ≥160/minute
• offensive liquor or meconium stained liquor
Management
• Transfer from a clinic or community health centre to a district hospital (or specialist hospital if the gestation is
below 32 weeks). Chorioamnionitis is an indication for delivery of the foetusfoetus.
• Give ampicillin two grams of IV followed by one gram of IV six hourly, with metronidazole 400 mg orally three
times daily; if allergic to penicillin use Clindamycin, intravenously, 600 mg eight hourly instead of ampicillin.
• Induce labour with a bulb (Foley Catheter), misoprostol or oxytocin if vaginal delivery is possible (see later-
induction of labour). Try to avoid a caesarean delivery as far as possible, but do it for the usual indications.
• During labour, monitor the foetusfoetus closely, with CTG if possible.
• Continue ampicillin (or Clindamycin) and metronidazole for five days after delivery.
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DEFINITIONS
Prolonged pregnancy
Pregnancy exceeding 42 weeks (294 days).
Postdates pregnancy
Pregnancy exceeding the Estimated Date of Delivery (EDD).
Clinical (uncertain) prolonged pregnancy

Where the dates are unsure, and it is clinically estimated that the pregnancy exceeds 42 weeks.
Post maturity syndrome

When placental insufficiency has developed in a prolonged pregnancy.
The most serious associated problems with prolonged pregnancy are intrapartum related birth asphyxia, meconium
aspiration, feto-pelvic disproportion and postmaturity syndrome. The management is as follows:
• With certain gestation:
○ pregnancy is induced beyond 41 weeks. Ensure that the gestational age has been correctly calculated
○ at 41 certain weeks of gestation, stretch and sweep the membranes and refer the mother from a clinic or
community health centre to a district hospital for induction of labour within the next three days
○ during labour, monitor the foetusfoetus with CTG if possible
• When the EDD is unsure, induction at a suspected 42 weeks is not advisable but careful foetal surveillance is
done. Do a stretch and sweep of the membranes at every visit.
○ foetal surveillance: do a weekly CTG and ultrasound amniotic fluid assessment
○ induce labour only once the largest deepest amniotic pool is ≤3 or the AFI ≤5
○ if ultrasound is not available, do a foetal lung maturity test
INDUCTION OF LABOUR WITH A LIVE BABY

The most frequent indications for induction of labour at district level are post term pregnancy, hypertensive disorders and
pre-labour rupture of membranes. Only induce labour in a hospital with 24 hour emergency operating theatre capacity.
Elective delivery must only be done with a valid indication and beyond 39 weeks gestation (or with proven lung maturity
if gestation is unsure and the indication valid).
Contra-indications for induction of delivery at a district hospital

• placenta praevia
• transverse lie persisting after attempted version
• breech presentation
• foetal distress
• previous caesarean section
• parity ≥5
Approach to induction of labour

• confirm the indication
• examine the mother carefully to confirm gestational age and presentation
• assess the Bishop score- use the table and assign points for a total score
• perform a pre-induction CTG
If all prerequisites are fulfilled, and the pre-induction CTG is normal; induction of labour can be performed using one of
the available methods.
The Bishop score for cervical assessment

Points given: 0 1 2 3
Cervical dilatation (cm) <1 1-2 2-4 >4
Cervical length (cm) >4 2-4 1-2 <1
Station -3 -2 -1/0 Engaged
Cervical consistency Firm Average Soft
Cervical position Posterior Mid-position Anterior
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Cervix favourable: (Bishop score ≥ 9)

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• If HIV negative, (or HIV positive on HAART >4 weeks/ or with recent undetectable viral load)- rupture the
membranes; and start oxytocin if there are not adequate contractions within two hours.
• If HIV positive and viral load unknown, or on HAART for <4 weeks; start oxytocin with membranes intact, or use
misoprostol.
Cervix unfavourable: (Bishop < 9)

• Mechanical cervical dilatation (Bulb induction) is the first line of induction agent:
○ pass a sterile Foley catheter (F16-18, with a 30 mL balloon) through the internal cervical os, during a sterile
speculum exam or with vaginal examination; and inflate it with 30-50 mL of water
○ put it on gentle traction against the cervix by strapping the catheter to the thigh. To maintain gentle
traction, periodic repositioning of the distal tip on the thigh may be necessaryAlternatively, it can be put on
traction with a piece of string suspended over the foot end of the bed with 2x200 mL bags of fluid used as
counterweight
○ as soon as the bulb is expelled, do ROM or start oxytocin
○ the induction can be expedited by doing extra-amniotic saline infusion (EASI) through the catheter-
consider if the induction is urgent or catheter expulsion has not occurred after four to six hours:
• infuse an initial 200 mL saline bolus at room temperature through the catheter into the extra-amniotic
space
• continue with saline 40-50 mLs/h through the intra-cervical catheter
• do not exceed two litres in total
○ bulb induction should preferably not be done for patients with overt lower genital tract infection, severe
immuno-compromised patients/AIDS or patients with ruptured membranes (cover with antibiotics if no other
induction method feasible)
• Misoprostol is not registered for use in labour in South Africa, but its use has been extensively studied and the
WHO recommends a low dose (20-25 microgram) orally two hourly for induction of labour. The titration method
is less labour intensive, and CTG is required once the woman is in labour.
Misoprostol regimen (parity < 5; live baby, no previous surgery on the uterus).
• The maximum oral dose is 20 ug two hourly for 24 hours. Administer as follows:
○ Add a single 200 microgram tablet of misoprostol to a bottle of 200 mL tap water
○ Shake the bottle well until the tablet has dissolved. Discard unused solution after 24 hours
○ Give 20 mL of the solution orally every two hours, for 24 hours
• As soon as the woman reports painful contractions, do a vaginal examination and a CTG. If she is in
established labour, stop the misoprostol.
• If there are no contractions in 24 hours, repeat the Bishop score and act accordingly (bulb, oxytocin or rupture
of membranes if ≥ 9; if < 9 repeat misoprostol). Do not give oxytocin less than six hours after giving misoprostol.
• Do not repeat the misoprostol course more than twice.
• If there are no cervical changes after two courses of misoprostol, review the indication for induction.
• Do a Caesarean section for failed induction only if all the methods above have failed.
VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION (VBAC)
Antenatal care for a woman with one previous CS may be conducted at a clinic or community health centre, but labour
must be managed in hospital with continuous CTG and 24 hour theatre facilities. A doctor should see the mother at the
first antenatal visit (to review the history) and again at 36 weeks (to plan the mode of delivery).
Women with a previous caesarean section are at risk for ruptured uterus during labour. The woman must have reliable
transport if she chooses to VBAC; or stay in a maternity waiting home close to the hospital to await the onset of labour.
Indications for elective repeat caesarean delivery

• a previous vertical uterine incision (classical scar or any scar that extends into upper segment)
• previous ruptured uterus
• previous caesarean delivery for a very preterm baby where the type of incision is unknown
• two or more previous caesarean deliveries
• where the mother requests and elective CD after appropriate counselling
• other obstetric problems, e.g. multiple pregnancy, breech, transverse lie
• an estimated foetal weight >3500 g or a SF of 40 cm or more at term. (This may indicate a large baby and one
should be very cautious to allow VBAC)
• maternal BMI> 40
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Management of vaginal birth after caesarean delivery/section (VBAC)
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Management is similar to normal labour with the following precautions:
• exclude all the contraindications for VBAC listed above
• conduct labour in a hospital that can perform caesarean section on a 24-hour basis
• run an intravenous drip with Ringer’s lactate solution at 80-120 mL/hour and pass a urinary catheter to monitor
urinary excretion
• monitor with continuous CTG
• always use a partogram (do two hourly vaginal examinations once in active labour) and intervene timeously
• do not augment labour with oxytocin
• observe carefully for signs of imminent uterine rupture and do an emergency Caesarean section immediately if
rupture is suspected (any of the following signs):
○ foetal tachycardia or foetal heart rate decelerations
○ significant vaginal bleeding
○ macroscopic haematuria
○ strong abdominal pain between contractions
○ sudden cessation of contractions
Indications for emergency caesarean delivery at attempted VBAC:

• the latent phase of labour exceeds eight hours
• progress in the active phase of labour crosses to the right of the alert line (progress <1 cm/hour)
• here are signs of imminent uterine rupture (above)
Postpartum observations
Close observation is necessary during the fourth stage of labour, as the uterus may occasionally rupture during vaginal
delivery of the baby and only become evident after delivery. Signs of rupture, which should immediately be reported to
a doctor, include:
• rising maternal heart rate

• a fall in blood pressure values
• lower abdominal pain
• moderate to severe lower abdominal tenderness
• postpartum haemorrhage
• haematuria
If uterine rupture is suspected, do a laparotomy to repair the uterus. Obtain prior consent for hysterectomy, should this
become necessary.
Note: waiting mother’s areas should be considered for elective caesarean delivery and previous caesarean
delivery awaiting spontaneous labour for VBAC, if the patient has transport problems.
RHESUS INCOMPATIBILITY
Rapid rhesus (D) blood group testing must be done on all pregnant women at the first antenatal visit, or at delivery in
unbooked mothers. Rhesus-positive mothers need no further specific management.
If a mother is rhesus-negative*, send blood for atypical antibody testing at 24, 32 and 36 weeks (six weekly, align with
the BANC visits):
• if no antibodies are found, continue with antibody testing every six weeks
• if antibodies are found at a titre of < 1:16, repeat the antibody test every two weeks
• if antibodies are found at a titre of ≥ 1:16 send the mother to a unit that specialises in managing rhesus
incompatibility (usually a specialist referral hospital) within three days
If no antibodies are found, give prophylactic anti-D 100 µg intra-muscularly as follows:
• after delivery to all rhesus-negative mothers, if the baby is rhesus-positive or its rhesus status is unknown,
within 72 hours
• if amniocentesis or external cephalic version is performed
• if there is significant antepartum haemorrhage
• if the mother suffers any abdominal trauma
• after abortion, miscarriage or ectopic pregnanc.
*If the father of the baby is tested and also found to be rhesus-negative, no further management will be necessary, as
the baby will then be rhesus-negative.
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This is a history of poor obstetric performance in the absence of a demonstrable cause. Women with a poor obstetric
history should be referred from a clinic or community health centre to a hospital for assessment and further management.
TWO OR MORE CONSECUTIVE PREVIOUS SECOND TRIMESTER MISCARRIAGES OR THREE OR MORE

CONSECUTIVE FIRST TRIMESTER LOSSES
Need referral to a specialised unit after booking (if <34 weeks). In the older (>35 years) woman, consider referral
earlier. Manage the woman according to the plan from the specialist referral unit.
A cervical cerclage is only done for specific indications and in singleton pregnancies at a specialist referral centre. It
should not be done at district level. The specific indications include a history of three or more preterm deliveries and/or
second trimester losses, or a short cervix on ultrasound scan (<2.5 cm) before 24 weeks, plus a history of one or more
spontaneous mid-trimester loss or preterm birth.
PREVIOUS SPONTANEOUS PRETERM DELIVERY

This refers to the delivery of a preterm baby (<34 weeks) that died or required special care, in the last previous pregnancy.
Patients must be referred to a district hospital for initial work up. Refer for specialist management if possible. At the
hospital:
• do an ultrasound scan at the first antenatal visit, including estimation of the cervical length
• obtain a good history of the preterm birth(s)
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Chapter 10
MANAGEMENT OF INTRA-UTERINE DEATHS, STILLBORN BABIES
AND NEONATAL DEATHS

This chapter discusses the management of intra-uterine deaths, stillborn babies and
neonatal deaths, including legal definitions, diagnosis and management, postnatal
investigation of stillbirths and neonatal deaths and the management of a patient with a
previous stillbirth.
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CHAPTER 10 : MANAGEMENT OF INTRA-UTERINE DEATHS, STILLBORN BABIES AND NEONATAL DEATHS
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LEGAL DEFINITIONS
NON-VIABLE FETUS (MISCARRIAGE)
Less than 28 weeks* gestation and where there is no evidence of life at delivery.
STILL BIRTH
Gestational age of 28 weeks or more and where there is no evidence of life at delivery.
NEONATAL DEATH**
Death after a live birth whatever the duration of the pregnancy.
When the gestational age is not known, a legal weight cut-off of 1000 g is used.
*According to the Births and Deaths Registration Act, No. 51 of 1992, a stillbirth means that the fetus had at least 26
weeks of intra-uterine existence (or 28 weeks since last menstrual period), but showed no signs of life after complete
birth.
**Any infant that shows signs of life after birth is regarded as live born. These signs include breathing, beating of the
heart, pulsation of the umbilical cord, and/or definite movement of voluntary muscles.
All stillborn babies and neonatal deaths require a notification of death (form DHA-1663) and need to be buried or
cremated. Babies below 1000 g or 28 weeks can be incinerated according to hospital policy.
PPIP
For statistical purposes, all dead babies with gestational age of 22 weeks and more (or 500 g and more) are regarded
as perinatal deaths and must be recorded in the Perinatal Problem Identification program (PPIP).
Local gestational limits

• Certain specialised obstetric units have a lower limit for foetal viability (e.g. 27 weeks or 850 gram). Use the
limits of viability as determined by your referral unit.
• The viability of <28 weeks refer to the management of a pregnancy where delivery is imminent. In cases of
preterm labour, severe maternal disease, preterm rupture of the membranes etc. before 28 weeks where there
is a reasonable chance that further treatment can extend the gestation beyond 28 weeks, manage according to
the protocols in this book, including the administration of steroids, suppression of labour where indicated and
referral.
• All non-viable (<28 weeks) babies born in a CHC or district hospital must be evaluated at birth and given
supportive treatment; if the baby is strong and survives, contact a specialist referral hospital to obtain advice
on further management. Never abandon a live but non-viable baby or put him/her in a refrigerator or sluice,
no matter how small. Keep the baby warm and allow the parents to hold the baby or keep it comfortable in an
incubator or overhead heater.
• Complications of gestation <24 weeks are usually managed in a gynaecology or general ward, but use local
hospital protocols to guide you.
INTRAUTERINE DEATH (IUD)
DIAGNOSIS
Typical clinical findings
• absent foetal movements
• disappearance of symptoms of pregnancy
• symphysis-fundal height does not increase as expected
• difficult or abnormal foetal palpation
• foetal heart not heard
Making the diagnosis

• refer the woman to a hospital to confirm the diagnosis with an ultrasound scan
• offer induction of labour, but do not discourage a woman who wants to go home for a day or two to discuss and
make arrangements with her family. Some women prefer to await the onset of spontaneous labour
• consider a diagnosis of abruptio placenta if there is accompanying bleeding and hypertension
EXPECTANT MANAGEMENT
• Only for a completely stable patient with no maternal disease or rupture of membranes, who chooses this
management.
• See the mother weekly at the antenatal clinic.
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• Perform platelet count weekly after the presumed date of IUD, to detect coagulopathy (platelet count <100,000/
mm3). If the patient develops coagulopathy, refer to a specialist facility.
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Deliver if there is rupture of membranes, vaginal bleeding, abdominal pain, pyrexia or hypertension.
Induction of labour for IUD

• Follow the same protocol for induction as with a live baby, but delay amniotomy until late in the first stage
(cervix ≥8 cm dilated).
• Provide good analgesia - morphine 5 mg IM and promethazine 25 mg IM four hourly if necessary.
• Labour management follows the same principles as for normal labour - enter all observations, fluids and
medications on a partogram and treat labour abnormalities appropriately.
POSTPARTUM CARE
This differs from normal postpartum care in some aspects:
• be sympathetic and supportive at all times
• encourage the mother, or parents to hold and spend time with the baby
• if possible, transfer the mother to a non-maternity ward
• take into account the normal grief responses during counselling and refer to a social worker if available
• provide basic genetic counselling if an abnormality is suspected and refer appropriately
• explain the cause of foetal death to the mother, if known
• treat breast discomfort with simple analgesics, breast binding and fluid restriction
POSTNATAL INVESTIGATION OF STILLBIRTHS AND NEONATAL DEATHS
Where a birth defect or genetic disorder is suspected, the following steps should be followed to obtain a diagnosis so
that appropriate postnatal counselling may be provided about risks of recurrence of the condition in a future pregnancy.
History and basic external examination

• this may be done by a doctor or nurse
• obtain a full pregnancy history
• obtain a full family history
• ask about possible exposure to teratogens
• note whether there was oligohydramnios or polyhydramnios
• record head circumference, weight, length, right foot length, and all abnormal external clinical features
Placenta
Weigh the placenta and examine for:
• placental insufficiency- (placenta small with calcifications)
• abruptio placentae (definitive blood clot making an indentation in the placenta and covering at least 15 per cent
of the placental surface)
• infection (products of conception foul smelling, membranes opaque)
• true knots or other abnormalities in cord (examine for the presence of the expected one vein, two arteries)
Examination of a dead baby

• Weigh the baby; consider if foetusfoetus is small for gestational age- use a percentile chart.
• Examine if stillbirth is fresh or long standing (maceration).
• Look for signs of foetal macrosomia (very fat baby) - consider maternal diabetes.
• Look for obvious congenital abnormalities.
• Motivate parents to request a post-mortem examination, especially for a fresh, term stillborn where no diagnosis
can be made at birth. If congenital abnormalities are present, get consent for digital photography and whole
body X-ray from parents and send photographs to a geneticist for an opinion.
• If parents do not consent to post-mortem, do a whole body X-ray of baby to look for skeletal deformities.
• Cord around the neck is very seldom a cause of stillbirth.
Further management of the mother

• Do HbA1C (EDTA tube) to exclude diabetes; and blood group, HIV and syphilis tests (always repeat syphilis
tests, even if it was negative at the booking and 32 weeks test).
• Suppress breast milk, if indicated (tie breasts up, or prescribe Cabergoline (Dostinex® 1 mg orally- only
available on private prescription).
• Give adequate contraceptive counselling.
• Make follow up date at 6 weeks to discuss the results.
• If congenital abnormalities were present, refer to a genetic counsellor for counselling before the next pregnancy.
MANAGEMENT OF A PATIENT WITH A PREVIOUS STILLBIRTH AFTER 24 WEEKS
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A perinatal death in a previous pregnancy is an indication for a referral to a district or specialist hospital for evaluation/
assessment as soon as the patient books for her next pregnancy.
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If the previous loss was due to a documented non-repeatable cause (e.g. syphilis or cord prolapse) continue
management at the CHC.
• If a clear, repeatable cause is identified (e.g. late onset IUGR, diabetes, maternal lupus etc.), refer for specialist
management.
• If it was an unexplained death or unexplored previous loss, (no attempt made to find a diagnosis), rather refer
for specialist opinion and follow their instructions for further shared care.
• Patients with a previous unexplained stillbirth are at risk for development of maternal complications, especially
diabetes or pre-eclampsia in the following pregnancy and should receive antenatal care at a hospital, preferably
a specialist hospital. If they remain stable they can be induced at term (>39 weeks).
MANAGEMENT OF A STILLBORN “BODY” (28 WEEKS GESTATIONAL AGE AND MORE)
After the delivery of the foetusfoetus, the responsible midwife

• completes the relevant documentation:
○ nursing records
○ delivery register
○ early notification of birth
• Ensure correct identification of the body and placenta.
• The registered midwife ensures that the relevant documentation is completed:
○ doctor’s notes (if applicable)
○ notification of death (form DHA-1663- can be completed by a midwife if at a MOU/CHC)
○ consent for autopsy – if indicated
○ consent for cremation – if indicated
○ refer the patient for grief counselling as appropriate
• The responsible midwife must ensure that the consent for cremation is signed by the mother, if requested.
(Inform the patient whether ashes will be provided to parents according to the local policy.)
• Once all the relevant documentation is completed, the midwife can contact the mortuary for the removal of the
body.
MANAGEMENT OF A STILL BORN “BODY” BELOW 28 WEEKS GESTATIONAL AGE
The patient must be informed that current legislation has determined that the department of Home Affairs will issue no
death certificate for a fetus less than 28 weeks gestational age.
The responsible midwife must complete all the relevant documentation:

• nursing records
• delivery register
• early notification of birth
• consent for disposal of human tissue (inform the patient that no ashes will be provided to the parents after incin-
eration)
• referral for grief counselling where appropriate
• all bodies should be handled according to the CHC/hospital policy
If the mother is completely stable, she can be discharged from the CHC/MOU. If there is any underlying maternal disease
(abruptio placentae, severe hypertension or pre-eclampsia, severe blood loss, etc.) the mother must be stabilised and
transferred to the next level of care. If no emotional support service (social worker, grief counsellor) available at the
CHC, refer to the next level of care for grief counselling.
The clinical notes (maternity case record, delivery record and notification of birth) must be retained to ensure correct
completion of the relevant documents, entry in the PPIP programme and discussion at the morbidity and mortality
meetings and to plan for the six weeks follow up visit and next pregnancy.
MANAGEMENT OF A NEONATAL DEATH
In cases of neonatal death, the notification of death form has to be completed by a doctor. The mother, baby, placenta
and all relevant notes must be transferred to a hospital for further management by an ambulance or funeral undertaker
if there is no doctor available at the CHC/MOU.
Management of dead babies born before arrival (BBA)

These cases are managed by the police and the body usually goes for a forensic post mortem.
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Chapter 11
MEDICAL DISORDERS IN PREGNANCY

This chapter reviews the treatment for various medical disorders in pregnancy such at
anaemia, diabetes mellitus, cardiac disease, asthma, thromboembolism and epilepsy.
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ANAEMIA
All pregnant women should have an Hb measurement at the first antenatal visit, and if ≥10 g/dL it should be repeated
between 28 and 32 weeks and again at 36 weeks. Any Hb level of <10 g/dL should be followed up with more frequent
Hb measurements after initiating treatment. A haemoglobinometer should be used, so that the result is available at the
same visit.
Most cases of anaemia in pregnancy are caused by iron deficiency. There are multiple factors that can contribute to
iron deficiency in pregnancy, including poor diet and parasitic infestations such as hookworm and bilharzia. The iron
deficiency can be pre-existing, or it can occur for the first time in pregnancy due to the increased iron requirements.
Other causes of anaemia in pregnancy include folate (folic acid) deficiency and the anaemia of chronic infections such
as HIV and AIDS. Malaria is an important cause of anaemia in pregnancy in malaria areas. There is often a combination
of causes (e.g. iron and folate deficiency). Women with a multiple pregnancy are at higher risk of developing anaemia,
and should have their Hb checked monthly during the antenatal period.
PREVENTION OF ANAEMIA
• Give all women with Hb ≥ 10g/dL ferrous sulphate 200 mg oral daily and folic acid 5 mg oral daily for the
duration of the pregnancy (combined iron and folic acid preparations do not usually contain an adequate folic
acid dose, so folic acid should be given separately).
• Continue with iron and folic acid supplementation during lactation. Give advice on a balanced diet to prevent
nutritional deficiency.
• Steps to be taken to improve compliance with and absorption of oral iron tablets:
○ encourage honesty about compliance with medication
○ discourage consumption of soil, charcoal, etc
○ discourage excessive consumption of tea or coffee. Do not take more than two to three cups of coffee or
tea. Use rooibos tea, decaffeinated tea and coffee, water or fruit juice
○ advise taking iron tablets during meals if side effects are affecting compliance
○ avoid taking the iron tablets at the same time as calcium tablets
MANAGEMENT OF ANAEMIA
In all cases, look for an underlying cause, and address the cause where possible.
Referral criteria
Refer from a primary health clinic/ community health centre as follows:
Hb <6.0 g/dL Urgent transfer to hospital the same day.
Hb 6.0-7.9 g/dL Urgent transfer to a hospital if symptomatic (dizziness, tachycardia, shortness of breath at rest).
If not symptomatic, refer to the next high-risk clinic within one week.
Hb 8.0 to 9.9 g/dL Transfer to a high-risk clinic if no improvement after one month of treatment.
Hb <10 g/dL at 36 weeks gestation or more Transfer to hospital for further antenatal care and delivery.
Management of mild anaemia (haemoglobin 8-9.9 g/dL)

• Increase ferrous sulphate 200 mg to orally 3 times daily and continue with folic acid 5 mg orally daily.
• Follow up all women <36 weeks pregnant with mild anaemia with a repeat Hb after four weeks.
• If there is no response to oral iron/ folate treatment or if ≥36 weeks, refer to the district hospital for further inves-
tigations.
• If no response to oral iron treatment or if ≥36 weeks, and if iron deficiency confirmed (minimum investigation:
full blood count), consider intravenous iron therapy (in hospitals only). Intravenous iron will raise the Hb faster
than oral iron.
• Avoid blood transfusion if there are no other complications.
Management of moderate to severe anaemia (Hb ≤7.9 g/dL)

Investigate the anaemia at the hospital/high risk clinic and look for underlying causes:
• Take blood for a full blood count (FBC): the mean cell volume (MCV) indicates the probable cause of anaemia:
○ a below-normal MCV suggests iron deficiency anaemia (microcytic)
○ a normal MCV suggests anaemia of chronic disease (normocytic)
○ an above-normal MCV suggests folate or vitamin B12 deficiency anaemia (macrocytic)
○ if the FBC shows a microcytic picture, it is reasonable to initially treat as iron-deficiency anaemia
○ if the FBC shows a normocytic or macrocytic picture, do further tests: iron studies, red cell folate and
vitamin B12 levels to identify the cause
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• send urine away for microscopy and culture, and a stool sample for occult blood and parasites.
• do a malaria smear, where relevant
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start treatment for anaemia with ferrous sulphate 200 mg oral 3 times daily, and continue with folic acid 5 mg
oral daily
• if the Hb is <6.0 g/dL or if the patient is symptomatic (dizziness, tachycardia, shortness of breath at rest), then
she must be admitted to hospital
• avoid overloading with intravenous fluids
• transfuse only if symptomatic
• give one unit at a time over four to six hours
• review need for further transfusion after each unit transfused, based on symptoms, rather than Hb level. Give
furosemide 20 mg intravenously after each unit transfused
If there is a failure to respond to oral iron therapy, compliance with the supplements should be checked and the results
of iron studies, red cell folate and vitamin B12 levels should be checked and treat accordingly. If there is no response to
oral iron treatment or if ≥36 weeks, and if iron deficiency confirmed, consider administering parenteral iron therapy (in
hospitals only).
BLOOD TRANSFUSION FOR ANAEMIA

(See section on blood transfusion for further details)
• As a guideline, an anaemic patient should be transfused at least one unit of packed red cells if:
○ Hb <8.0 g/dL and the woman is going for an emergency caesarean section
○ Hb <6.0 g/dL and the woman is in labour (vaginal delivery anticipated)
• Patients booked for elective caesarean section should have their anaemia corrected, preferably by means other
than transfusion, before they undergo their caesarean section.
DIABETES MELLITUS
PREGESTATIONAL DIABETES MELLITUS

This is diabetes that has been present before the current pregnancy. These women require tight control of their blood
glucose levels from the time of conception and should book for antenatal care as soon as pregnancy is confirmed.
Ideally, they should plan their pregnancy, and attend a specialist clinic to optimise the control of their diabetes, before
they get pregnant.
Diabetic women who get pregnant should be referred to a specialist health facility/clinic with expertise in managing
diabetes in pregnancy. Follow-up care may be continued at a district hospital, in accordance with instructions from the
specialist clinic, depending on facilities, levels of skill, and the stability / control of her diabetes.
GESTATIONAL DIABETES MELLITUS

This is diabetes that develops during pregnancy or is diagnosed for the first time during the current pregnancy.
Screening and diagnosis

All pregnant women with risk factors for diabetes in pregnancy should be screened at the first antenatal visit and again
at 28 weeks, if the initial screen was negative
Note: for patients with pre-gestational diabetes (i.e. already known to be diabetic before pregnancy),
there is no need for diabetes screening. Screening is for at risk women who have not yet been diagnosed
as diabetic.
Figure 11.1: Risk factors for gestational diabetes

Underlying patient factors Patient from an ethnic group with high prevalence of diabetes (e.g. Indian)
Obesity (patient BMI ≥35)
Age ≥40 years
Previous history Previous history of gestational diabetes (diabetes in a previous pregnancy)
First degree relative with diabetes
Previous unexplained intrauterine fetal death
Previous macrosomic baby (birth weight ≥4 kg)
Current pregnancy Polyhydramnios
Fetus large for gestational age
Glycosuria (glucose 1+ or more on urine dipstick)
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There is a lack of consensus regarding the best screening method for gestational diabetes. Different screening methods
may be used depending on the preference at the local specialist referral centre. Clinics and district hospitals are therefore
advised to liaise with their specialist referral centre and follow their local recommendations regarding screening method
and diagnostic criteria.
For the convenience of both patients and health care professionals, it is recommended that the screening method
chosen should be one which can be done on-site on the same day that the women is first seen, and one which uses
glucometer readings, rather than laboratory tests.
Example of a screening method

• When the woman arrives at the antenatal clinic (unfasted) give oral glucose 75 g dissolved in 250-300 mL water
and take glucometer reading one hour after giving glucose.
• A value of ≥7.8 mmol/L is a positive test and indicates that a diagnostic glucose tolerance test is required. This
requires the patient to come back fasted on another day and may be done on-site or may require referral to a
high-risk clinic, depending on local specialist referral centre protocol.
Example of a diagnostic test

• The patient must be fasting (drink only water from 22:00 the night before). Do screening first thing in the morning.
• Take a fasting glucose test, and then give oral glucose 75 g dissolved in 250-300 mL water and take blood for
glucose level two hours after giving glucose.
• A fasting blood glucose level of ≥5.6 or a two hour value of ≥7.8 mmol/L indicates diabetes and the woman should
be managed as a gestational diabetic.
• Alternatively, the patient can bring her own breakfast to the clinic instead of the glucose load.
MANAGEMENT OF DIABETES MELLITUS

Referrals
• All pregnant women with pre-gestational diabetes should be referred to a specialist clinic with expertise in
managing these conditions in pregnancy, usually at a specialist hospital.
• Follow-up care may be continued at a district hospital, in accordance with instructions from the specialist clinic,
depending on facilities, levels of skill, and the stability / control of her diabetes.
• Screening for gestational diabetes can be done at clinics/CHCs.
• Any woman who tests positive should be given dietary advice and referred to the next high-risk clinic at the local
hospital within one week at the latest.
• Women with gestational diabetes can be managed at the district hospital level if blood sugar levels are controlled
on diet (fasting blood sugar <6 mmol/L, two hours post-prandial <8 mmol/L).
• If diet alone is inadequate to control blood sugar levels, then the patient should be referred to a specialist hospital
with expertise in managing diabetes in pregnancy.
• Follow up care may be continued at a district hospital, in accordance with instructions from the specialist clinic,
depending on facilities, levels of skill, and how stable the diabetic control is.
• Management of any diabetic at a district hospital must be “shared care” with a specialist health facility.
Initial management of gestational diabetes

• Advise the woman to start with lifestyle modifications (stop smoking, moderate exercise), dietary advice
immediately and refer to a dietician.
• Call the woman back to the high-risk clinic two weeks later; advise her to come “fasted” in the morning, carrying
her breakfast with her.
• Check fasting blood glucose level (glucometer) on arrival and then two hours after breakfast (post-prandial).
• If fasting blood sugar <6 mmol/L, post-prandial <8 mmol/L, it is appropriate to continue with dietary
management. Recheck fasting and post-prandial blood glucose every two weeks.
CARDIAC DISEASE
At the first antenatal visit, all women should be asked about a history of heart disease (including heart operations and
attendance at cardiac clinics), and about current symptoms of heart disease. Clinical examination of the cardiovascular
system should include auscultation of the heart. As a minimum the blood pressure must be checked and the pulse rate
checked separately (manually).
SYMPTOMS AND SIGNS

• shortness of breath at rest or with mild exercise
• shortness of breath when lying flat
• haemoptysis
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• palpitations
• chest pain
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• loud heart murmurs
REFERRALS
From primary health clinic / community health centre:
• all women with symptoms or signs of cardiac disease or with a history of cardiac disease must be referred to a
doctor to confirm or exclude cardiac disease
• stable patients must be referred to a high-risk clinic within one week, while unstable patients (e.g. respiratory
distress) should be referred to the hospital urgently
From district hospital to a specialist hospital:

• all women with a diagnosis of cardiac disease should be referred to a regional or tertiary centre with expertise in
the management of cardiac conditions in pregnancy
• stable patients could be booked at the specialist antenatal clinic
• unstable patients should be transferred as an emergency
• further management of the pregnancy and delivery should follow the instructions of the specialist centre
MANAGEMENT DURING LABOUR

Cardiac patients should deliver in a specialist health facility and can be referred there if in early labour. However,
there may be occasions when a cardiac patient presents in advanced labour to the MOU/CHC or the district hospital
and may deliver there before transfer can be arranged. The following recommendations must be followed in such
circumstances:
First stage of labour

• Nurse the mother with her upper body raised to 45 degrees.
• Secure intravenous access (for drug administration), but avoid giving large amounts of intravenous fluids (use a
200 mL fluid bag and run slowly if at all). Oral fluids should be available to the patient whenever thirsty.
• Give adequate analgesia - Pethidine 100 mg IM with Promethazine 25 mg IM and/or nitrous oxide 50 per cent
and oxygen 50 per cent (Entonox®) as required.
• Give Ampicillin 1 g IV six hourly and Gentamicin 240 mg IV as a single dose; or Vancomycin 1 g IV as a single
dose (for women allergic to penicillin).
Second and third stage of labour

• Avoid the lithotomy position: the mother must remain upright or semi-upright when delivering, with her legs
supported by two assistants below the level of her chest.
• Once the foetal head has engaged and the mother is bearing down, perform instrumental delivery unless
delivery is rapid and easy.
• Local anaesthetics for episiotomy should not contain adrenaline. Episiotomy should not be done routinely.
• Do not give ergometrine or Syntometrine® in the third stage; instead use oxytocin 10 units intramuscularly.
• Give furosemide (Lasix®) 20 mg intravenously after delivery of the baby.
Fourth stage and puerperium

• The first 24 hours post-delivery is the most common time for the cardiac patient to decompensate and go into
pulmonary oedema.
• Try to avoid intravenous fluids. If an oxytocin infusion is required to control or prevent PPH, it should be given in
concentrated form (20 units in 200 mL, at 20 mL/hour).
• High-care observations in a high-care setting are required for at least 24 hours post-delivery. Thus, even
after an uneventful delivery, transfer to a specialist hospital is recommended for observations and specialist
assessment, and to arrange follow-up for the cardiac problem and for post-partum sterilisation if requested by
the mother.
MANAGEMENT OF PULMONARY OEDEMA

• Nurse the mother with her upper body raised to 45 degrees.
• Give oxygen by facemask.
• Secure intravenous access (for drug administration), but avoid giving intravenous fluids.
• Give Lasix® 40 mg intravenously, and repeat if necessary.
• Give morphine five mg as slow intravenous bolus.
• Transfer immediately to a specialist hospital for further care.
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REFERRAL
• Pregnant women with an acute asthmatic attack must be referred as an emergency from a clinic / CHC to the
district hospital.
• Women with a history of asthma (no current attack) should be referred to the next high-risk antenatal clinic.
Women with recurrent severe attacks should be referred to a centre with specialist physicians/ pulmonologists.
• Management of asthma in pregnancy does not differ from that in non-pregnant women. Beta-2 stimulants (e.g.
salbutamol), inhaled and systemic steroids, aminophylline and ipratroprium bromide are all safe in pregnancy.
• Manage labour and delivery according to normal obstetric principles.
• Women who are on chronic oral steroid treatment should rec eive hydrocortisone 100 mg IV six hourly during
labour or at the time of caesarean section.
THROMBOEMBOLISM (VTE)
Women are at increased risk of thromboembolism in pregnancy and in the puerperium. Thromboprophylaxis may be
required throughout pregnancy and the puerperium for the highest risk patients, including those with:
• a previous personal history of VTE
• strong family history of VTE
• patients with prolonged immobility (e.g. due to AIDS or paraplegia)
These patients should be discussed and managed in conjunction with a specialist hospital.
SIGNS/SYMPTOMS OF DEEP VEIN THROMBOSIS (DVT)

• acute unilateral diffuse leg swelling
• pain
• redness
• heat
Pulmonary embolus may present with acute shortness of breath and tachycardia, with or without chest pain or
haemoptysis. Consider pulmonary embolism as a cause of recurrent episodes of unexplained chest pain.
REFERRAL
Any suspected case of DVT or pulmonary embolus should be referred urgently from clinic / CHC to hospital to be
reviewed by a doctor. If clinical assessment by the doctor at the district hospital suggests DVT or pulmonary embolus,
then the patient should be urgently referred to a specialist facility to confirm the diagnosis.
MANAGEMENT OF DVT IN PREGNANCY

• If there is a strong suspicion of DVT or pulmonary embolus start treatment with low molecular weight heparin
sub-cutaneous e.g. enoxaparin one mg/kg twice a day.
• Alternatively, use unfractionated heparin sub-cutaneous 20 000 units immediately, followed 12 hours later by 15
000 units twice a day.
• Arrange transfer to a specialist centre to confirm diagnosis and advise on further management.
• Warfarin therapy is acceptable for women from the second trimester up to 36 weeks’ gestation if heparin treat-
ment throughout pregnancy is not feasible.
EPILEPSY
Ideally, women with epilepsy should plan their pregnancy, and attend a specialist clinic to optimise the control of their
disease and review the anti-epileptic drug regimen, before they get pregnant.
REFERRALS
• A pregnant woman with an acute epileptic seizure should be stabilised and referred from clinic/CHC to hospital
for further treatment and observation.
• A pregnant woman with epilepsy or suspected epilepsy (no acute seizure) should be referred to the next high-
risk antenatal clinic.
• A pregnant woman with recurrent seizures despite treatment should be referred to a specialist health facility for
management and shared care where possible.
MANAGEMENT OF EPILEPSY IN PREGNANCY

• Arrange a second trimester detailed ultrasound scan to exclude foetal abnormalities.
• The anti-epileptic drug of choice in pregnancy is carbamazepine. However, do not change non-carbamazepine
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treatment during pregnancy (e.g. phenytoin) if it is controlling the seizures.
• Use carbamazepine blood levels (through levels, before the morning dose is taken), if available, to monitor
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• Use monotherapy if possible.
• The dose of antiepileptic medication may need to be increased from the pre-pregnancy dose to maintain control
during the pregnancy due to the increased volume of distribution.
• Give folic acid five mg oral once daily throughout the pregnancy; ideally this should be started before
pregnancy.
• From 36 weeks add vitamin K 20 mg oral once daily (for all women on phenytoin).
• Always exclude other causes of seizures e.g. eclampsia or meningitis, even in a known epileptic.
• Treat status epilepticus as for non-pregnant women.
Obstetric care, labour and delivery are the same as for non-epileptic women. Breastfeeding is not contra-indicated
when the mother is on anti-epileptic drugs; however, the control of seizures should be good before the mother is
allowed to care for her new born without supervision. Readjust treatment to pre-pregnancy doses after delivery.
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Chapter 12
INFECTIONS IN PREGNANCY

This chapter discusses the various infections during pregnancy that need to be
carefully monitored and treated. These include sexually transmitted infections, acute
pyelonephritis and malaria.
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SEXUALLY TRANSMITTED INFECTIONS
ABNORMAL VAGINAL DISCHARGE

Vaginal discharge should be considered abnormal if it is itchy, excessive, yellow or green, or offensive-smelling.
Wherever possible, use a vaginal speculum to observe the discharge and inspect the cervix.
Vaginal Candidiasis
• Vaginal Discharge Syndrome Thick, white vaginal discharge with itch.

• Give a clotrimazole pessary to insert into vagina that evening.
• If vulval burning/itching give a clotrimazole cream to vulva twice daily, continue for three days after symptoms
resolve for maximum of two weeks.
Treat syndromically for gonorrhoea, chlamydia and trichomonas, with triple antibiotics:
• Ceftriaxone 250 mg IM as a single dose
• Azithromycin one gram orally as a single dose (azithromycin 1 g stat is an alternative to amoxicillin; stat dose
would be preferable compared to prolonged course of amoxicillin. See the new STI guidelines)
• Metronidazole two grams stat (can be used in all trimesters of pregnancy)
Severe penicillin allergy

Avoid ceftriaxone. This includes a history of any of the following:
• angioedema
• anaphylactic shock
• bronchospasm
• steven-johnsons syndrome
Replace ceftriaxone with high dose azithromycin two grams orally as a single dose (Spectinomycin 2 g IM currently
recommended for gonorrhoea in penicillin allergic patients; however increasing the dose of azithromycin would be
simpler. See the new STI guidelines). This high dose will treat both gonorrhoea and chlamydia.
If symptoms persist after seven days, repeat treatment if possible reinfection or poor adherence to treatment; otherwise
refer the patient to specialist care. Notify the partner to come for examination and treatment.
Doxycycline is not part of these guidelines and should be avoided in pregnant women.
GENITAL WARTS
These are caused by the human papilloma virus (HPV) and are sexually transmitted. They can be external on the
vulva or perineum, or internal in the vagina or on the cervix.
Treatment
• Podophyllin is contraindicated in pregnancy.
• If small (<10 mm), soft and involve the skin, no treatment is indicated in pregnancy and can be treated
postpartum.
• If very large, bleeding or infected, refer to a doctor.
• Consider elective caesarean delivery if warts are very large and may obstruct vaginal delivery.
• Do a Pap smear (if not done within the past year); this can be done up to 30 weeks’ gestation.
GENITAL ULCERS
Painful small ulcers

Treat for genital herpes:
• acyclovir 400 mg orally eight hourly for seven days
• pain relief if necessary; keep lesions clean and dry
• counsel that HSV infection is life long and recurrent episodes may occur
• if the first ever episode of genital herpes (primary infection) occurs in the third trimester, there is a risk of
neonatal herpes. Refer the patient: caesarean section may be advised
• patients should be advised to inform their partners. Sexual transmission of HSV can occur even in the absence
of symptoms
Painless ulcer with or without swollen inguinal lymph nodes

• Take blood for syphilis tests (see below for treatment of positive syphilis test in pregnancy).
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• Treat for primary syphilis and chancroid:
○ Benzathine penicillin 2.4 million units IM single dose and azithromycin 1 g orally single dose
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• Refer for further investigation of primary syphilis; if primary syphilis proven, admit to hospital for penicillin
desensitisation (see figure 14.1, page 142). Only penicillin will adequately prevent transmission to the
foetusfoetus, and prevent congenital syphilis. There are no proven alternatives.
If no improvement within a week

• Refer
• Notify partner to come for examination, syphilis and HIV testing, and treatment.
Note that a genital ulcer caused by syphilis will resolve spontaneously within 4-6 weeks without treatment;
however the syphilis infection persists, and the ulcer resolving does not represent cure.
SYPHILIS AND POSITIVE RPR TESTS
SYPHILIS SCREENING IN PREGNANCY

• Rapid syphilis screening must be done at the first antenatal visit.
• If the first test is performed before 20 weeks and is negative, a second test should be done at 32-34 weeks.
• A rapid card test, done in the antenatal clinic, gives a result before the woman goes home. This allows
immediate treatment. .
Treatment
• Treat all women with a positive screening test, irrespective of titre.
• Give benzathine penicillin, 2.4 million units IM once weekly, for three doses.
URINARY TRACT INFECTION
CYSTITIS
This presents with urinary discomfort and/or frequency. There may be some lower abdominal tenderness. The patient
usually has no fever and does not appear ill. Urine dipstick testing may show any of leucocytes, nitrites or protein.
Asymptomatic bacteriuria is a condition in pregnancy that sometimes precedes acute pyelonephritis, and may be
associated with preterm labour. If detected on urine culture, it should be treated in the same way as cystitis.
Management
• If possible, send a midstream urine specimen for microscopy, culture and sensitivity (MC&S).
• Treat empirically with a suitable oral antibiotic. The first line choice of antibiotic should be guided by advice from
the local microbiologists, based on sensitivity patterns of UTIs in the local area. Possible choices include
○ Cephalexin 500mg qid for five days
○ Nitrofurantoin 100 mg orally four times daily for seven days (only before 36 weeks)
○ Cotrimoxazole two tablets twice daily for five days
• If urine culture is positive, change antibiotics according to sensitivity results. Discuss with microbiologist at your
laboratory if advice needed on antibiotic choice.
• Avoid use of co-amoxyclav as first line empirical therapy, as it should be reserved for cases of severe sepsis,
and it has been associated with an increased risk of necrotising enterocolitis when given in cases of pre-labour
preterm rupture of the membranes.
• Encourage a high oral fluid intake.
ACUTE PYELONEPHRITIS
This is a common and serious cause of pyrexia in pregnancy, and may precipitate pre-term labour. The patient usually
appears ill and has a pyrexia and tachycardia. There is almost always renal angle tenderness.
Management
• Admit to hospital.
• Obtain a midstream urine specimen for MC&S.
• Take blood for urea and creatinine, FBC and smear, and blood culture.
• Ciprofloxacin is contraindicated in pregnancy. Therefore the following empiric antibiotics should be used, with
de-escalation to narrower spectrum antibiotics once organism and sensitivities available:
• Cystitis or mild pyelonephritis:
• – Coamoxiclav one g po 12 hourly
• – Duration five days for cystitis, 14 days for pyelonephritis
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• If urine culture is positive, change antibiotics according to sensitivity results. Discuss with microbiologist at your
laboratory if advice needed on antibiotic choice.
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Ensure a high oral fluid intake: give Ringer-Lactate solution IV 3 L/day, or more if dehydrated. Give anti-emetics
if vomiting.
• Refer the patient if renal impairment, or not responding to treatment within 48 hours.
• Following treatment, take two further urine specimens for MC&S to ensure that the infection is eradicated.
Penicillin allergy
• Ciprofloxacin 400 mg IV 8 hourly; change to oral ciprofloxacin 500 mg bd 24-48 hours after fever subsides.
• Treatment with ciprofloxacin requires only seven days in total.
Alternative
• Gentamicin five to six mg/kg intravenous daily; treat for 14 days; should only be given if therapeutic drug
monitoring is available. Do not give in renal impairment.
MALARIA
Malaria in pregnancy is associated with serious complications. These are due both to the effects of a severe febrile
illness in pregnancy, and to the malaria parasite itself, which becomes sequestered in the placenta, and in the small
blood vessels of the brain, kidneys and other organs. Foetal complications include miscarriage, preterm delivery, foetal
growth restriction, and perinatal mortality. Severe maternal complications include cerebral malaria, hypoglycaemia,
ARDS and maternal death.
Most severe malaria in South Africa is due to Plasmodium falciparum; drug treatments below are for falciparum malaria.
For treatment of non-falciparum malaria, consult local guidelines. If unsure of species, treat for P falciparum. Malaria is
a notifiable disease.
PITFALLS IN THE DIAGNOSIS AND TREATMENT OF MALARIA

Not recognising the diagnosis
• Malaria presents as a febrile illness, with a wide differential diagnosis. There are no specific symptoms or signs.
It can often be mistaken for influenza, or another viral infection.
• Jaundice or anaemia and thrombocytopenia may be the leading symptoms.
• Cerebral malaria and eclampsia may be difficult to distinguish. If in doubt, treat for both.
• People from endemic areas are a major risk group when moving to a country where malaria is not endemic:
their immunity wanes over time, and they do not realise that returning to their home country can result in severe
malaria.
• The ‘VFR’ group of patients (Visiting Friends and Relatives) are often not recognised by healthcare workers
as at risk. Always ask patients about travel history, and for people from other countries in Sub-Saharan Africa,
when they last returned home.
Delay in laboratory testing

• Alert the laboratory to test the specimen urgently, and to phone the result to a named doctor caring for the
patient.
Not recognising that severe malaria is a medical emergency

• All pregnant women with malaria should be admitted to hospital.
• All pregnant women with severe malaria should be admitted to the highest possible level of care: preferably an
intensive care or high care unit in a tertiary hospital.
• Disease severity can easily be underestimated: if a patient is diagnosed with uncomplicated malaria, regular
and repeated examination is necessary.
Not ensuring that the first dose of malaria treatment is given when it is prescribed
• Do not just write the prescription chart – ensure the medicine is given. The best rule is that the prescribing
doctor gives the first dose. Medication delays can cost the life of mother and baby.
DIAGNOSIS OF MALARIA
• Thick and thin blood film: for parasite count, and to confirm the species and stage of parasites. The parasite
count is also used for monitoring response to treatment.
• Rapid diagnostic test (RDT) using a finger prick blood sample, for diagnosis of malaria antigen. These are less
sensitive than the malaria blood film; a blood film should always be requested. RDTs are very useful in hospitals
where may be readily available, with an offsite laboratory needed to read a blood film.
• In a febrile patient where suspicion of malaria is high, a single blood film cannot rule out malaria. Three blood
films over 12-24 hours are necessary to rule out the diagnosis.
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Uncomplicated malaria
• Patient shows none of the clinical or laboratory features below.
• Patients have mild symptoms, are ambulant, with normal mental function and no organ dysfunction.
Severe malaria
• Patient shows one or more of the clinical or laboratory features below.
• If the patient has any clinical evidence of severe malaria, start treatment. Do not wait for the laboratory tests
listed below to be available.
Figure 12.1: Assessing malarial severity

Clinical features
• Impaired consciousness
• Convulsions
• Severe weakness (unable to sit)
• Hypotension (systolic BP < 80 mmHg)
• Respiratory distress (acidotic breathing or RR > 30 breaths/minute)
• Visible jaundice
• Macroscopic haematuria
• Abnormal bleeding: (eg retinal haemorrhages, DIC)
Laboratory features
• Hyperparasitaemia (>4% parasites)
• Severe anaemia (Hb< 5 mg/dL)
• Hypoglycaemia (Hgt < 2.2 mmol/L)
• Acidosis (pH < 7.25 or plasma bicarbonate < 15 mmol/L)
• Renal impairment (serum creatinine >250 μmol/L)
• Hyperlactataemia (venous lactate > 4 mmol/L)
• Hyperbilirubinaemia (bilirubin > 50 μmol/L)
Management of uncomplicated malaria (none of the features of severity are present)

• If a patient with uncomplicated malaria is vomiting, give an antiemetic, e.g. metoclopramide. Repeated vomiting
after antiemetic treatment is an indication for intravenous treatment.
Oral artemether-lumefantrine (Coartem)

• Four tablets (80mg artemether and 480 mg lumefantrine) immediately (if > 35 kg).
• Repeat dose after eight hours on day one.
• Then repeat dose 12 hourly on following two days: five doses in total.
• Give each dose with fat containing food/drink to ensure adequate absorption.
If artemether-lumefantrine is not available

• Oral quinine, 600 mg eight hourly for seven to ten days.
• Add oral clindamycin 10 mg/kg 12 hourly for seven days, two to three days after starting quinine.
General measures for treating uncomplicated malaria

• Admit all pregnant women with malaria to hospital, monitor blood sugar four hourly.
• Monitor regularly for clinical and laboratory markers of severity; if any deterioration, change to IV treatment and
refer.
• • Ensure adequate hydration, but avoid over-hydration: see note on ARDS as above.
• Control pyrexia; fan or tepid sponge, paracetamol may be given, avoid NSAIDS (nephrotoxic).
Follow up
• • All women with ongoing pregnancies need follow up at hospital antenatal clinic due to the risk of impaired
foetal growth.
Management of severe malaria
• Severe malaria is a medical emergency, ideally requiring intensive care unit treatment.
• After rapid clinical assessment and confirmation of the diagnosis, give correct dose of IV treatment immediately.
Transfer urgently for specialist care.
• Good nursing care is vital.
• If it is not possible to transfer the patient immediately discuss with an Infectious Diseases Specialist, Intensive
Care Specialist or Physician at the referral centre, and transfer as soon as possible.
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• Start intravenous quinine: loading dose of 20 mg/kg stat, in 5 mL/kg of 5 per cent dextrose saline, by slow intra-
venous infusion over four hours. This is followed by quinine 10 mg/kg given over four hours, every eight hours.
Give IV treatment for at least 24 hours.
• Monitor blood glucose for hypoglycaemia
• Monitor respiratory rate and oxygen saturation
• Monitor all intake and output
• Add broad-spectrum antibiotics to treat secondary bacterial infection
• Reduce high body temperatures (> 39°C) by tepid sponging and anti-pyretics
Figure 12.2 below shows the outpatient oral desensitisation protocol for patients with penicillan allergy.
Figure 12.2: Outpatient oral desensitisation protocol for patients with penicillan allergy
Resulting Amount in ml of the
concentration concentration to be Cumulative
Penicillin V (250mg/5ml strength) suspension concentration: Units
(units/mL) swallowed (add to ~30ml dose (units)
water for easier drinking)
1 Dilute 1ml suspension into 80ml of water 1,000 0.1ml 100 100
2 Dilute 1ml suspension into 80ml of water 1,000 0.2 ml 200 300
3 Dilute 1ml suspension into 80ml of water 1,000 0.4 ml 400 700
4 Dilute 1ml suspension into 80ml of water 1,000 0.8 ml 800 1,500
5 Dilute 1ml suspension into 80ml of water 1,000 1.6 ml 1,600 3,100
11 Use undiluted suspension 80,000 1.0 ml 80,000 176,700
14 Use undiluted suspension 80,000 8.0 ml 640,000 1,296,700
Use oral penicillin V (phenoxymethyl penicillin) suspension (250mg/5ml strength; 5 ml is equivalent to 400 000 Units).
Dilute as follows and administer orally every 15-20 minutes:

• Observe for 30 minutes after last oral dose before parenteral administration of penicillin.
• Can be performed in an outpatient setting with emergency resuscitation equipment ready to manage
anaphylactic reactions; it must be prescribed by a doctor. Start early in the morning so that the procedure is
completed long before the clinic closes. Stop if there are any skin reactions, vomiting or severe itching/flares.
• Example: first step: take 1ml Pen V oral solution (250mg/ml) and add it to 80ml of water. Take 0.1ml of this
solution, add it to 30ml of water and give to the patient to drink
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Chapter 13
HIV AND TUBERCULOSIS IN PREGNANCY

This chapter discusses the management of HIV positive women during and post
pregnancy, including treatment for the infant. It also examines HIV and TB co-
infection and other opportunistc infections.
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CHAPTER 13: HIV AND TUBERCULOSIS IN PREGNANCY

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HIV POSITIVE PREGNANT WOMEN
PMTCT is part of an expanded package of care for the mother-infant pair, and their family. This chapter is an overview
of the 2015 National Consolidated Guidelines . For more in-depth information, consult the full guideline. Ensure that
any guideline updates are available in your clinic, and that any guideline changes are disseminated to all staff, and are
rapidly implemented.
The full guidelines are available from:
http://www.health.gov.za/docs/Policies/2014/HIV_Guidelines_Jan 2015-final.pdf
There are four elements of PMTCT care:
• primary prevention of HIV, especially among women of childbearing age

• preventing unintended pregnancies among women living with HIV
• preventing HIV transmission from a woman living with HIV to her infant
• providing appropriate treatment, care, and support to women living with HIV and their children and families
PMTCT IN ANTENATAL CARE
AIMS
• Identify all women who are HIV positive including those who seroconvert during pregnancy and breastfeeding.
• Provide ART the same day HIV positive status is known, to optimise maternal health and to prevent mother to
child transmission of HIV.
• Ensure HIV positive pregnant and breastfeeding women are virologically suppressed on ART.
HIV COUNSELLING AND TESTING
• All pregnant women should be encouraged to book for antenatal care early i.e. as soon as they believe they are
or are confirmed to be pregnant.
• HIV counselling and testing (HCT) should be offered to all pregnant and breastfeeding women with unknown
HIV status or those who tested negative three or more months previously.
• HCT should be offered at the first antenatal visit, and if HIV negative, follow the HCT protocol for repeat testing
(see below).
• All women should be given routine information about HIV testing and the PMTCT programme. This includes
a group information session, followed by individual counselling for women who have never tested, or have
previously tested negative. Consent must be obtained before testing, at a minimum verbal consent is required.
• A rapid test should be performed on a finger prick sample of blood. If the test is positive, a second rapid HIV test
using a test kit from a different supplier should l be performed on a second finger prick sample. If both tests are
positive, the woman is confirmed HIV positive.
• If the first rapid test is positive and the second rapid test is negative, then a laboratory ELISA test performed on
a venepuncture blood sample. The healthcare provider should explain the reason for the laboratory test, and
the woman should be asked to return for the ELISA results. Results should be obtained within a week.
• Post-test counselling should be offered to both HIV positive and HIV negative women.
• Women who opt-out of HIV testing should have individual ‘post refusal’ counselling where risks of MTCT to the
unborn baby should be highlighted.
• HIV testing should repeatedly be offered to HIV negative women at each antenatal visit.
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Figure 13.1: HIV counselling and testing. (Figure 1, National Consolidated Guidelines)
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Women with a confirmed positive result:

• Should be clinically staged (see Annexure 1, National Consolidated Guidelines (2015:108), bloods for
serum creatinine and CD4 count (to determine eligibility for Cotrimoxazole prophylaxis).
• All women should be started on the Fixed Dose Combination (tenofovir/emtricitabine/efavirenz) on the
same day, unless there are contraindications .
• Women should return within seven days for CD4 count and creatinine results.
• All pregnant women (HIV+ or not) should be encouraged to use condoms .
• Partner involvement is important to encourage condom use throughout pregnancy and breastfeeding.
ELIGIBILITY FOR ART

• All HIV positive pregnant and breastfeeding women, and postnatal women within one year are eligible
for lifelong ART, irrespective of CD4 count or feeding choice.
Other adults and adolescents that are15 years and older:

• CD4 ≤ 500 cells/mm3 irrespective of clinical stage
• WHO stage three or four irrespective of CD4 count
Hepatitis B virus co-infection or active Tb disease, irrespective of CD4 count or clinical stage
Women who test negative:

• all pregnant women are part of the PMTCT programme, regardless of whether they test positive or negative
• seroconversion in pregnancy or while breastfeeding has a high risk of vertical transmission, due to a high
maternal viral load and the absence of infant prophylaxis. In South Africa, 4 per cent of women who were
initially HIV negative become positive later in pregnancy .
• all pregnant women (HIV+ or not) should be encouraged to use condoms to prevent serovonversion during
pregnancy
• partner involvement is important to encourage condom use throughout pregnancy and breastfeeding is
important
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• all pregnant women who test HIV negative are to be offered repeat HIV testing every three months during
antenatal and either inin early labour/ or immediately following delivery (irrespective of when was the last test
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done), at the six weeks EPI visit, and every three months throughout breastfeeding period
• all pregnant women irrespective of HIV status must be offered a TB screening test at each repeat visit
Women already known to be HIV positive:

• if not on ART, do clinical staging, take blood for CD4 count (to determine eligibility for Cotrimoxazole
prophylaxis) and creatinine. Start FDC the same day if no contraindications
• if already on ART for >3 months, take blood for viral load, irrespective of when this was last done
• switch to FDC, if on other first line ART , virologically suppressed, with no contraindications to FDC
ANTENATAL MANAGEMENT
Initial assessment
In addition to the above, the following should be done for all HIV positive women:
• routine booking investigations: haemoglobin, rhesus status, syphilis
• symptom screening for TB and eligibility for isoniazid preventative therapy (IPT); see section on TB below
• clinical screening for STIs
• screening for active psychiatric illness
• clinical and laboratory screening for renal disease, including serum creatinine
• initiation of lifelong antiretroviral treatment
INITIATION OF ART FOR HIV POSITIVE PREGNANT WOMEN

• All HIV positive women at any time in pregnancy or breastfeeding, or known to be HIV positive but not yet on
treatment, should be initiated on the FDC unless there are contraindications.
• Contraindications to the FDC are active psychiatric disease or history of renal disease. If either apply, the
woman has a high risk pregnancy and needs urgent referral. Start AZT 300mg bd if Hb ≥ 7g/dl on the day of
booking. The referral centre will start alternative triple therapy.
• The woman must return within seven days for serum creatinine and CD4 results.
• If creatinine > 85µmol/L stop FDC and start AZT 300mg bd if Hb is 7g/dl or more, and refer. The referral centre
will start alternative triple therapy.
• If Hb is less than 7g/dl
• Ensure the CD4 count results are available and acted upon.
If CD4 < 200 cells/mm3 start cotrimoxazole prophylaxis. This is also necessary in women with WHO stages two,
three or four disease, or active TB.
If CD4 < 100 cells/mm3, screen for cryptococcal disease. Send blood for serum cryptococcal latex antigen test;
see section on cryptococcal disease below for further information.
Women with renal disease:

• Tenofovir is contraindicated.
• This includes women with a history of renal disease, or creatinine If creatinine > 85µmol/L in pregnancy.
• Women with renal disease have high risk pregnancies; they need urgent referral to investigate the underlying
cause, and will need ongoing antenatal care and delivery at a referral unit. They need alternative triple therapy,
with dose adjustment if necessary. Most commonly this would be AZT/3TC/EFV, in the absence of anaemia.
Women with active psychiatric illness:

• Efavirenz is contraindicated.
• These women also have high risk pregnancies, and need urgent referral for management of their psychiatric
illness, and alternative triple therapy.
• The alternative to efavirenz depends on CD4 count:
• CD4 < 250 cells/mm3: nevirapine 200mg per day for two weeks, followed by 200mg bd
Baseline ALT is necessary; nevirapine toxicity still occurs at
lower CD4 counts: if rash or jaundice develops, stop nevirapine
and refer the patient
• CD4 ≥ 250 cells/mm3: lopinavir/ritonavir two tablets bd
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Figure 13.2: Algorithm for initiation for ART in HIV positive women (figure 4, National Consolidated Guidelines)
VIRAL LOAD TESTING
• virological suppression is essential to optimise maternal health and prevent opportunistic infections, and to
prevent vertical transmission.
Women on ART at booking:

• for women on art for > 3 months, viral load testing should be done at booking, irrespective of when the last test
was done. see algorithm below
• if viral load (vl) is < 1000 copies/ml it is repeated six monthly until the end of all breastfeeding.
if vl > 1000 copies/ml:

• provide intensive adherence counselling. repeat vl in one month. if the second vl is undetectable or has shown
a reduction of 1 log (10 fold reduction) or greater, continue with the existing regimen.
• if the second vl has not shown a reduction of one log or greater, or has increased, she should be switched
to second line treatment urgently (see table 13.1 below). if she is already on second line, discuss with an hiv
experienced doctor.
Note: that the true measure of virological suppression (undetectable vl) is vl < 50 copies/ml. if vl is 400-1000 copies/
ml, adherence must be assessed, with additional adherence counselling. if there are concerns about adherence, an
additional VL test can be done earlier than six months. Discuss with an HIV experienced doctor.
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Figure 13.3: Algorithm for the management of pregnant women already on ART for > 3 months (Figure 5, National
Consolidated Guidelines).
Women initiated on ART in pregnancy:

• Women who are initiated on ART at booking or any other time during pregnancy and breastfeeding need a viral
load test after three months on treatment.
• Management depends on whether the VL is < 1000 copies/ml or > 1000 copies/ml, according to the above
algorithm.
• If viral load at three months after initiation of ART is suppressed, do six monthly VL until the end of
breastfeeding.
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Figure 13.4: Algorithm for VL monitoring in HIV positive pregnant women not yet on ART or newly diagnosed HIV
positive in pregnancy.
Switching to second-line treatment:

• Any woman who requires a switch to second line ART must have intensive adherence counselling to ensure
high level adherence and rapid viral load suppression.
• Recommended second line regimens are shown in table 1. Note that Atazanavir/ritonavir cannot be given with
rifampicin. If patient is on TB treatment, and change from lopinavir/ritonavir, consult with a specialist.
• Hepatitis BsAg must be checked before stopping tenofovir: if positive, stopping tenofovir may lead to a fatal
hepatitis B flare. Tenofovir should be continued as a 4th drug in the regimen.
Table 13.1. Recommended second line treatment for patients failing first-line regimen(Table 8, National
Consolidated Guidelines).
LABORATORY MONITORING FOR WOMEN ON ART

Women on tenofovir containing regimens (including women on FDC):
• Serum creatinine at three months, six months,12 months and every 12 months.
• The upper limit of normal for creatinine in pregnancy is 85µmol/L.
• If there is any evidence of renal impairment, refer the patient for investigation of the cause, and to change from
tenofovir to alternative ART, with dose adjustment if necessary (most commonly this would be to AZT/3TC/
Efavirenz, in the absence of anaemia i.e. HB<7g/dl).
Women on AZT containing regimens:

• Hb at three months and six months and every 12 months
LABOUR AND DELIVERY
INTRAPARTUM MANAGEMENT
HIV positive women on ART:

• ensure that the regimen and duration of treatment is documented
• ensure the latest viral load result is available. If this has not been done according to the schedule above, it
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Women previously testing HIV negative, or women of unknown status:
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• repeat HIV test in labour if in the first stage (regardless when it was last done), or after delivery if in the second
stage
HIV positive women not on ART, newly diagnosed HIV positive women:
• this includes unbooked women, and women newly testing HIV positive
• ART management is given in the next section
Infants need birth PCR and extended infant prophylaxis; see section below.
Unbooked women
• offer HCT, if agrees, test and act upon results as per guidelines.
Antiretroviral treatment
Women on ART:
• continue treatment throughout labour and delivery; ensure all doses are taken. No additional treatment is
necessary.
Women newly diagnosed HIV positive in labour, or known HIV positive and not on ART:
• single dose nevirapine 200mg plus single Truvada (tenofovir/embtricitabine)
plus:
• AZT 300mg orally every three hours
Emergency casesarean section in HIV positive woman not on ART:

• single dose nevirapine 200mg plus single Truvada (tenofovir/embtricitabine) prior to the procedure
For all women presenting in labour not on ART:

• start FDC the next day, if no contraindications, and request CD4 count and serum creatinine
• provide ART adherence counselling
• if she is discharged the same day, ensure the CD4 and creatinine results are available at the three to six day
postnatal visit.
MANAGEMENT OF LABOUR
Vaginal delivery
Safer delivery technique:

Mother to child transmission is increased in the following situations, which should therefore be avoided.
• Artificial Rupture of memebranes (AROM) as a means of augmenting labour unless there is a specific
obstetric indication.
• Prolonged rupture of membranes. The duration of ruptured membranes prior to delivery should be as
short as possible (ideally 4 hours or less).
• Instrumental delivery.
• Invasive monitoring procedures e.g. foetal blood sampling and episiotomy.
• Following delivery, suctioning of the airway (trachea) of the neonate should only be performed if there is
meconium stained liquor and the baby is born flat and needs resuscitation. If so, a laryngoscope must be used
to allow suctioning under direct vision, before mask ventilation is commenced. If there is no skilled attendant
who can perform larygnoscopy, proceed directly to mask ventilation. For neonates born with meconium stained
liquor who are vigorous at birth secretions can be wiped away, with gentle suctioning of the nose and mouth
only if needed.
• Prophylactic antibiotics are not required for HIV positive women who have normal deliveries.
Pre-labour rupture of membranes

• Augment labour if not in spontaneous labour after four hours
• Prophylactic antibiotics as for all women with pre-labour rupture of membranes
Caesarean delivery
Caesarean delivery in HIV positive women is performed for the same obstetric indications as in HIV negative women.
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Surgical Prophylaxis
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Since HIV positive patients are at Immunocompromised and at increased risk of post surgical wound infections,
prophylactic antibiotics are given for both elective and emergency caesarean delivery :
• Cefazolin 1g IVI should be given prior to surgery followed by a broad-spectrum antibiotic (ceftriaxone,
amoxicillin-clavulinic acid) for three to five days.???
POSTNATAL CARE
All Infants born should receive skin-to-skin contact with their mothers, regardless of the mother’s HIV status
almost immediately after delivery. All infants should start feeding within an hour after delivery. The benefits of
breastfeeding and the risks of not breastfeeding should have been discussed during antenatal care;.
Exclusive breastfeeding:
• South Africa actively promotes, protects and supports exclusive breastfeeding.
• All HIV positive women should be encouraged to exclusively breastfeed for six months, with appropriate
complementary food being introduced from six months and to continue breastfeeding for up to 12 months.
• The risks of mixed feeding within the first 6 months must be discussed (giving breast milk together with formula,
water or other foods or fluids (excluding prescribed medications).
• The only exception is infants of mothers on second or third line ART and VL > 1000 copies/ml; these infants
should not be breastfed, and formula feed provided.
• Formula feeds will be available on prescription by appropriate healthcare professionals for mothers, infants and
children with approved medical conditions.
• If the mother has decided to exclusively formula feed, she should bring infant formula with her, which should be
provided within one hour of deliver.
INFANT HIV TESTING
Birth HIV PCR testing
• All infants born to HIV positive mothers must be done HIV PCR testing at birth.
• Other subsequent tests must follow at 10 weeks and rapid antibody test at 18 months.
• Infants who are breastfed will require another PCR test six weeks post cessation of breastfeeding.
Infants of mothers newly diagnosed HIV positive while breastfeeding:

• an immediate PCR is indicated for the infant
If the infant tests positive, at any age:

• urgent referral/telephonic discussion with a paediatric HIV expert is needed for ART initiation
• send a second confirmatory test (HIV PCR if < 18 month old, or HIV antibody test if > 18 months old): however
do not delay initiation of ART while awaiting results of the test.
Infant prophylaxis
In order to make breastfeeding safer, all HIV-exposed children should receive prophylactic NVP from birth for six
weeks. If there is no breastfeeding, the infant must take NVP until six weeks of age.
• All infants are given post-exposure prophylaxis with nevirapine syrup from birth for at least six
• Some infants require extended nevirapine prophylaxis for 12 weeks, or dual prophylaxis with AZT and
nevirapine (see below). The mother’s ART history and viral load is essential to determine if the infant
needs additional prophylaxis; this therefore must be documented.
• After infant prophylaxis is completed, prevention of MTCT depends on the mother remaining virologically
suppressed on ART. It is essential that adherence is maintained, and viral load testing performed.
• In several cases daily NVP will be required beyond six weeks (see Table 13.2 below).
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Table 13.2: Eligibility criteria for ART prophylaxis in HIV-exposed infants
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Mother Infant regimen Comment
Mother on lifelong ART NVP at birth and then daily for 6 weeks Mother has been on ART for >4 weeks prior to delivery
Mother did not get any ART before or during NVP as soon as possible and daily for 12 weeks extended NVP is only necessary if the
delivery and tests HIV-positive >72hours 12 weeks (if infant is breastfed) infant is being breastfed. Check feeding practice at
post-delivery the 6 week EPI visit to ensure infant receives correct
OR duration of prophylaxis.
Mother newly diagnosed HIV-positive within 72
hours of delivery If mother received no ART before delivery, infant
OR should receive birth PCR.
Mother started ART less than 4 weeks prior to
delivery. An additional HIV PCR test is required 4 weeks after
NVP is discontinued.
This extended period of infant prophylaxis is required

to allow time for maternal viral suppression. It takes up
to 12 weeks for the viral load to become undetectable.
Breastfeeding mother diagnosed with HIV NVP and AZT immediately Do HIV PCR and return for results in 7 days
If infant tests HIV PCR negative: stop If infant <6 weeks, repeat HIV PCR at 6 weeks.
Start mother on a FDC immediately AZT and continue NVP for 12 weeks Additional HIV PCR 4 weeks after stopping NVP.
and initiate ART immediately.
Infant HIV testing 6 weeks post-cessation of
If mother has received 12 weeks of breastfeeding (either HIV PCR or ELISA depending
ART then infant NVP can be stopped. on age).
Unknown maternal status for any reason, Give NVP immediately* If rapid test is positive do an HIV PCR. If negative,
including orphans and abandoned infants Test infant with rapid HIV test* repeat HIV PCR at 6 weeks. If HIV PCR positive,
If positive continue NVP for6 weeks initiate baby on triple ART immediately and send
If negative discontinue NVP confirmatory HIV PCR
Mother with latest viral load >1000 copies/ml Dual ARV for 6 weeks (NVP and AZT). PCR at birth, if negative follow up with a 6 week HIV
Perform an HIV PCR at or shortly after PCR
birth Manage the mother as per Table 7
If repeat maternal viral load >1000 copies/ml then
refer to/discuss telephonically with paediatric expert
before the infant is 6 weeks old and prophylaxis is due
to be discontinued
Infants of mothers on 2nd or 3rd line regimens and
VL>1000 should not be breastfed
Non-breastfeeding mother diagnosed with HIV If more than 72 hours since delivery, Do HIV PCR, if <18 months
no infant NVP Do rapid test if >18 months,
Perform an HIV PCR, if positive initiate Repeat PCR 6 weeks after last HIV
ART
Dosing guide for nevirapine, AZT and cotrimoxazole:
Table 13.3. Dosing guide for nevirapine, AZT and cotrimoxazole in infants. (Table 11. National Consolidated
Guidelines)
See Algorithm below for infant prophylaxis and PCR testing
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Figure 13.5: Infant prophylaxis and PCR testing for infants of known HIV positive pregnant women, and
women newly diagnosed within 72 hours of delivery. (Figure 7, National Consolidated Guidelines).
Infants of mothers of unknown status for any reason, including orphans and abandoned infants:
• test infant with rapid HIV test

• START nevirapine prophylaxis immediately (unless rapid test result available within two hours)
• if rapid is positive, do an HIV PCR, and continue nevirapine for six weeks, if PCR is positive, refer to/discuss
telephonically with paediatric HIV expert to start ART
• if rapid is negative, discontinue nevirapine
Women diagnosed HIV positive during breastfeeding:

• start mother on FDC, unless contraindicated
• HIV PCR for the infant
• infant management depends on whether breastfeeding is continuing and infant PCR result: see algorithm in
figure 13.5
• if the infant PCR is negative, nevirapine prophylaxis should be stopped at 12 weeks only if the mother has been
on ART for more than 12 weeks, and has a viral load < 1000 copies/ml
Cotrimoxazole prophylaxis:
• all HIV exposed infants should start cotrimoxazole prophylaxis for Pneumocystis jirovecii pneumonia from four
to six weeks after birth
• Cotrimoxazole syrup should be continued until the infant is confirmed to be HIV uninfected, by PCR or antibody
testing at least six weeks after all breastfeeding is ceased
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Discharge from the health facility

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Information given to all women:

• the need for consistent maternal ART adherence and infant prophylaxis
• the importance of exclusive breastfeeding for the first six months
• contraception, especially use of condoms should be emphasised and these services must be offered to all
women before discharge
• follow-up at a named health facility within three to six days and again at six weeks postpartum
• have a correctly completed Road to Health book (it is mandatory this is fully completed)
• have a finalised plan for the mother-baby pair before discharge, and be given documentation and referral letters
• mothers and their infants should receive healthcare at the same consultation regardless of service point
• All women newly initiated on ART :
• be given a supply of ART for themselves, and a six weeks supply of infant prophylaxis
• be followed up after two weeks to assess adherence and side effects, align ART management with their
postnatal/EPI visits
TERMINATION OF PREGNANCY
HIV positive pregnant women who have undergone termination of pregnancy must receive antibiotics. Treatment of any
obvious genital infection is mandatory before the procedure is undertaken. Women undergoing TOP are also eligible for
lifelong ART. Ensure contraception is discussed and given with emphasizes on the use of condoms.
Regimen
• Doxycycline100mg orally twice daily for five days.
• Ciprofloxacin 500mg stat.
• Metronidazole 400 mg orally three times a day over five days or 500mg suppository every 12 hours for three
days.
IMPROVING MATERNAL HEALTH AND PREVENTING MATERNAL MORTALITY: TB AND OTHER

OPPORTUNISTIC INFECTIONS
HIV positive pregnant women who are acutely or chronically unwell need investigation for TB and other opportunistic
infections.
• Level one hospitals should refer to level two or level three if they do not have the resources for appropriate
investigation and management, if diagnosis of the underlying cause is not readily determined, or if there is
evidence of organ dysfunction (jaundice, renal impairment, respiratory distress, neurological problems ).
• There should be a low threshold for admission of women who are chronically unwell, for inpatient investigation
and management.
• Medical problems in HIV positive pregnant women should not be attributed to ‘advanced HIV’, the underlying
cause must be investigated.
• Initiate treatment promptly, do not delay, reduce or withhold treatment because of pregnancy; the benefit of
treatment far outweighs any theoretical risks to the foetusfoetus.
Prophylaxis of opportunistic infections

• All women with CD4 <200, WHO stages two, three, or four disease or active TB should start co-trimoxazole two
tablets daily.
• Discontinue when CD4 >200 for more than six months.
TUBERCULOSIS (TB) IN PREGNANCY
Non-pregnancy related infections remain the most common cause of maternal mortality in South Africa. TB is the single
most common cause. The national consolidated guidelines strongly emphasise that screening for TB is an essential
component of antenatal care. Deaths from TB also occur in HIV negative women.
• All pregnant women should be symptom screened for TB at every visit, with early detection, and prompt
initiation of TB treatment essential.
• All HIV positive pregnant women who are acutely or chronically unwell need investigating for TB.
Symptom screening for TB

At all antenatal visits and other contacts with maternity services – ask the following:
• cough of any duration
• fever
• night sweats
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If positive for any symptom:

• collect two sputum samples (ask the patient to cough outside), and send to laboratory for GeneXpert and
microscopy and culture, as per National TB guidelines
• do this at the antenatal clinic; do not refer to a TB clinic to collect sputum, this causes avoidable delays
• ensure the patient has a follow up appointment for the results
• if she has not yet initiated ART, do not start until TB diagnosis made and treatment started
• ART should be initiated within two to eight weeks after starting TB treatment, as for non-pregnant HIV positive
patients with TB. If CD4 < 50 cells/mm3, initiate ART within two weeks of TB treatment, when symptoms are
improving and TB treatment is tolerated
If symptom screen is negative for all symptoms:

• HIV positive pregnant women are eligible for Isoniazid Preventative Therapy (see below).
If sputum sample shows drug sensitive TB

• Start TB treatment as per national guidelines.
• All of the oral drugs are safe to use in pregnancy.
• Women taking Aluvia based ART need to double the dose if they are taking rifampicin: increase to four tablets
twice a day.
If sputum sample shows rifampicin resistant TB:

• drug resistant TB should be confirmed by culture and sensitivity
• ensure that INH sensitivity and second line sensitivities are requested
• • discuss with local Infectious Diseases (ID) specialists or senior doctors at local TB hospital for advice on
regimen
• drug resistant TB has a high mortality, particularly without an aminoglycoside as part of the regimen; for this
reason ID specialists would generally recommend that an aminoglycoside should be included as part of the
regimen in pregnancy despite any potential risk to the foetus
If sputum sample is negative and there are ongoing symptoms of TB

• HIV positive patients with TB and low CD4 counts more frequently have negative sputum smears, may have
normal CXR, and more often have disseminated TB.
• If symptoms persist, or there are additional clinical findings (for example, peripheral lymphadenopathy, pleural
effusion) refer promptly for inpatient or outpatient investigation; empiric TB treatment may be necessary. Refer
to an HIV/TB experienced doctor.
• Do not delay initiation of ART in pregnant women due to long delays in diagnosis of TB or initiation of treatment:
discuss with local TB clinic or referral centre about starting empiric TB treatment if there is a strong suspicion of
TB, but it has not been proven.
Management of infants born to mothers with TB:

• if the mother has active TB, BCG vaccination at birth should not be given
• the infant should be screened for congenital TB
• management of the infant is shown in the algorithm below
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Figure 13.6: Management of infants born to mothers with TB (Figure 10, National Consolidated Guidelines).
Isoniazid Preventative Therapy (IPT) for pregnant and breastfeeding women
IPT has been shown to reduce the incidence of TB in all people living with HIV, including those on ART. All HIV positive
pregnant women who screen negative for TB are eligible for IPT. This can be started irrespective of whether she is on
ART prior to the pregnancy, or whether ART is started in pregnancy. Initiate once the patient is stable on ART.
Who is NOT eligible for IPT:

• people with confirmed or unconfirmed active TB
• active liver disease, acute or chronic
• excessive alcohol use, more than 21 units/week for women
• symptoms of peripheral neuropathy
• people who have completed treatment for MDR or XDR TB
• history of adverse reaction to isoniazid
IPT regimen:
• Isoniazid 5mg/kg daily to a maximum of 300mg daily
• Pyridoxine 25mg daily
Duration of treatment:
• TST positive: 36 month
• TST negative or not available: 12 months
• for HIV positive pregnant women who have a positive TST, IPT can continue for 36 months
Symptom screening for TB should still continue at all visits to maternity services:
• if symptom screen is positive, discontinue IPT and send two sputum samples as above.
Adverse effects of isoniazid:

Discontinue IPT and refer if any of the following occur:
• drug induced liver injury: symptoms are jaundice, right upper quadrant pain or tenderness, nausea and vomiting
• skin rash
• peripheral neuropathy (numbness and/or tingling of the feet)
OTHER OPPORTUNISTIC INFECTIONS (OIs) IN HIV POSITIVE PREGNANT WOMEN
• HIV positive pregnant women with low CD4 counts are at risk of other opportunistic infections in addition to TB.
• Stage four defining opportunistic infections have a high mortality. The most common are Pneumocystis jirovecii
pneumonia, and cryptococcal meningitis, and both are significant causes of maternal mortality.
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• Pregnant women who are unwell need prompt and intensive investigation for opportunistic infections.
Starting ART in pregnant women with OIs
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In general, start ART two weeks after initiation of treatment for OIs.
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• However, for cryptococcal meningitis, it is recommended that ART is delayed for four to six weeks after initiation
of treatment, because early ART leads to increased mortality. If a pregnant woman has cryptococcal meningitis,
discuss with local Infectious Diseases specialists regarding when to start ART. In certain cases it may be
justified to start ART earlier than four weeks to reduce the risk of vertical transmission.
Screening for Cryptococcal disease

• Cryptococcal disease generally occurs with CD4 < 100 cells/mm3.
• The CD4 count taken at booking must be available at the next antenatal visit one week later, and the result
documented.
• Pregnant women with CD4 counts < 100 cells/mm3 who are not on ART at booking should be screened for
cryptococcal disease with serum cryptococcal antigen testing.
• If this is positive, all pregnant women should be referred for lumbar puncture; see figure 13.7: pregnant women
count as ‘special situations’.
If lumbar puncture shows a positive cryptococcal antigen test:

• Admit and treat for cryptococcal meningitis. This is with intravenous amphoterocin B, oral fluconazole 800mg
daily, and regular therapeutic lumbar punctures to reduce intracranial pressure. It is recommended that
pregnant women with cryptococcal meningitis are managed on medical wards by experienced doctors, and not
obstetric wards.
If lumbar puncture shows a negative cryptococcal antigen test:

• treat as as an outpatient with fluconazole 800mg for two weeks
For both groups, after initial two weeks of treatment:
• Fluconazole 400mg daily for two months, then 200mg daily for a minimum of one year, and until CD4 > 200 on
two occasions
• There have been concerns that high dose fluconazole (800mg daily) may be teratogenic if given daily through-
out the first trimester. However given the high risk of severe morbidity and mortality, the benefits of treatment
are considered to outweigh the risks
Figure 13.7. Screen-and-treat algorithm for ART-naive adult patients with a CD4+ T-lymphocyte count
<100 cells/μl (for cryptococcal disease. (Figure 11, National Consolidated Guidelines).
Guidelines for the prevention, diagnosis and management of cryptococcal meningitis in HIV infected
persons, N P Govender et al, 2013)
PNEUMONIA IN PREGNANT WOMEN
Respiratory disease is a significant cause of maternal mortality. Respiratory symptoms or signs need prompt investigation:
a raised respiratory rate (>24 per minute) is indication of underlying respiratory disease, and further investigation is
indicated. Treatment of pneumonia is the same as in non-pregnant patients.
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Chapter 14
GUIDELINES FOR PERINATAL REVIEW MEETINGS AT FACILITIES

This chapter provides detailed information on conducting perinatal review meetings;
including who should attend, what the meeting should focus on, how it should be
run and pre and post meeting actions.
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The PNRM is a key component of the broader audit process that aims at improving the quality of perinatal care and
perinatal outcomes.
PURPOSE OF THE PERINATAL REVIEW MEETING

The PNRM is a key component of the broader audit process that aims at improving the quality of perinatal care and
perinatal outcomes.
The following are achieved through the PNRM

• Reviewing perinatal (including maternal) outcomes.
• Following trends in perinatal indicators.
• Identifying gaps in the provision of quality perinatal care.
• Determining actions to prevent deaths and morbidity from similar causes.
• Identifying progress on action plans identified at the previous meeting.
• Sharing good practices and providing educational input.
• Building relationships between hospital and clinics, and amongst different the participants at the facility.
• Monitoring implementation of policy guidelines.
WHICH FACILITIES SHOULD HOLD PERINATAL REVIEW MEETINGS?

• Every hospital should hold perinatal review meetings, and these need to be attended by the representatives from
the Community Health Centres, midwife obstetric units, and clinics in the catchment area of the hospital.
• Every community health centre and all midwife obstetric units conducting more than 50 deliveries per month
(these facilities should still attend the PNRM at the referral hospital as well).
HOW OFTEN SHOULD THE PNRM BE HELD?

• At least monthly in District Hospitals.
• In CHCs and MOUs, it may be sufficient to conduct them quarterly, depending on the number of deliveries.
• In Regional or District Hospitals with large numbers of deliveries (e.g. over 500 per month), it may be useful to
conduct PNRM weekly in order to accommodate discussion of a larger number of mortality or morbidity cases.
However, there are certain components of the meeting which are better suited to a monthly schedule, such as the
statistics presentation and the setting of an action plan. Therefore where weekly PNRMs are held, there should
be a different format or agenda, depending on which week of the month it is.
• The PNRM should be scheduled at a regular time each month (or week) so that the participants can plan their
schedule accordingly. The dates of the meetings should be distributed well in advance (e.g. yearly).
WHO SHOULD ATTEND THE PNRM?

An attendance register should be developed that specifies the people (designation) that should be present at the
PNRM, with a space provided for them to enter their name and sign in their attendance.
Participation in the perinatal mortality meetings should be included in the performance agreements of the participants
listed below, and monitored.
District Hospital
• At least one representative from the senior hospital management (CEO, Medical Manager, Nursing Manager-all
three if possible).
• The Doctor in charge of maternity.
• The Doctor in charge of neonatal ward.
• All available doctors, including sessional doctors, who have to cover maternity and/or neonates- even if just on-
call.
• Operational managers in Maternity.
• Relevant facility-based programme coordinators (e.g. PMTCT) and trainers.
• All available hospital midwives (excluding those who never work in the maternity/neonatal sections).
• Hospital quality assurance manager.
• Hospital monitoring and evaluation manager.
• Facility information officer.
• Primary Health Care Supervisors who cover the catchment area of the hospital.
• Representatives from each of the community health centres and clinics in the catchment area of the hospital.
• Community outreach facilitators.
• DCST (ideally the obstetrician, advanced midwife and primary health care nurse should attend). At the mini-
mum, there must be a representative.
• District MCWH and PMTCT Coordinators.
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• Visiting outreach specialists (obstetric, neonatal) and medical students from regional and or tertiary referral
hospital.
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Representative of relevant NGOs working in the district.
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• Nursing College Representative and student midwives (where local college exists).
• According to the cases discussed, some may attend the PNRM by invitation, for example:
○ social worker
○ dietician
○ ambulance representative
○ anaesthetic specialist from regional and or tertiary referral centre
Regional Hospital
All of the above should attend, and in addition:
• medical students doing obstetrics or neonatal rotations
• medical interns doing obstetrics or neonatal rotations
• if meetings are held weekly, it is acceptable for the top management of the regional hospital to limit their
attendance to the specific meetings (e.g. monthly) where the action plans are made and followed-up on
• according to the cases discussed, some may attend the PNRM by invitation, for example:
○ HOD or other doctors from Anaesthetics, General Medicine Department, or other specialised departments.
WHAT IS THE ROLE OF SENIOR MANAGEMENT IN THE PERINATAL REVIEW MEETINGS?

• To take responsibility for the meeting occurring regularly and running smoothly according to the principles in this
document.
• Be involved in decision making and action planning.
• Facilitate implementation of actions decided on at the meetings.
• To be role models for their subordinates in encouraging quality improvement in the facility.
• The representation of senior hospital management is required in the PNRM so that they can keep in touch with
what is happening in their institution with regard to perinatal care.
HOW TO ENCOURAGE DOCTORS TO ATTEND THE MEETING?

• Accreditation of PNRM for CPD points.
• Presence of senior management at the meetings.
• Include participation in PNRMs in performance agreements.
HOW LONG SHOULD THE MEETING TAKE?

• For PNRMs which are held on a monthly basis, the recommended duration of the meeting is two hours.
• If a joint perinatal and child mortality meeting is held, then the meeting may take longer.
• If a weekly meeting is held, it may be reasonable to restrict the meeting to one hour per week.
WHO SHOULD CHAIR THE MEETING?

• Senior manager in maternity or neonatal department, either medical or nursing.
• Can have a rotating or a fixed chair, depending on the circumstances within the hospital.
• If the medical or nursing manager of the hospital has a special interest and expertise in perinatal care, they
could chair the meeting. This would increase the ownership by management of the perinatal audit process and
the actions that flow from the audit.
• However, whoever chairs the meeting must have been involved in preparing for the meeting and must
be familiar with the statistics, the cases that will be presented, and the actions required. The chair is also
responsible for ensuring the minutes are completed and distributed timeously.
WHAT SHOULD THE AGENDA INCLUDE?

• welcome
• distribution and signing of attendance register
• apologies
• ratification of previous meeting minutes
• matters arising from minutes: with a specific focus on following-up on the actions planned at the previous
meeting
• presentation and discussion of statistics. This should include information about referrals to the next level of
care, and the outcomes of these cases at the referral unit
• case presentations and discussion of cases
○ all maternal deaths need to be presented
○ selected perinatal deaths
• educational topic (e.g. presentation/discussion/demonstration)
• summary of key issues and setting of new action plan
• announcements
• date of the next meeting
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WHAT PREPARATION SHOULD THERE BE FOR THE MEETING?

• A schedule of PNRMs for the year needs to be published at the beginning of the year, and dates planned should
be adhered to.
• There should be a small committee at the facility responsible for the preparation of the meeting. As a minimum
this should include the chairperson of the meeting, and a senior manager from both nursing and medical
components (e.g. nurse manager and clinical manager for maternity).
• The committee must ensure the following is done in preparation for the meeting:
○ every maternal and perinatal death should have been discussed and analysed prior to the meeting (ideally
within 72 hours of the event). Where there is little mortality this could be extended to cases of severe
morbidity. Perinatal deaths should have been analysed according to the PPIP format
○ confirm the agenda for the meeting
○ prepare monthly statistics (may be done together with Faculty Information Officer). While the previous
month’s stats should be prepared for presentation, it is also important to present the trends over time for
certain key perinatal indicators
○ select cases for presentation (all maternal deaths and selected perinatal deaths with learning points)
○ prepare of educational topic for presentation
○ select and notification of presenters for the various presentations
○ prepare of preliminary action plan (based on stats and lessons to be learnt from selected cases). The
action plan will be further developed through discussion at the meeting
○ invitations can be sent by email or fax as a reminder prior to each PNRM. This is important especially for
those who will have to travel to the meeting from other facilities
○ organise transport to transport participants from the clinics where necessary
○ copy the prepared attendance register
○ prepare the venue
○ copy minutes of the previous meeting (just a few copies, as the minutes of the previous meeting should
have been distributed within a week of the previous meeting, and participants should come with their copy
of the minutes)
WHAT FORMAT SHOULD THE MINUTES BE WRITTEN IN?

• A standardised format (template) for recording the minutes should be used to make taking the minutes an
easier task (a suggested template with instructions is attached).
• The minutes must be a functional document which contributes to the quality improvement process of perinatal
audit.
• The minutes should be concise. They are not a detailed record of everything that is said at the meeting.
• The attendance register should be attached as an addendum.
• The key components of the minutes should be:
○ the main issues/gaps in perinatal care identified through the statistics and the case presentations
○ the action plan to address these issues
○ feedback on progress with implementing the previous month’s action plan
• In the minutes, a brief summary is all that is required regarding:
○ monthly statistics (a few key indicators)
○ cases presented
○ educational topic presented
• However, if requested by the participants, copies of the full statistics presentation, the educational presentation,
and the case presentations could be attached as an addendum.
WHO SHOULD TAKE THE MINUTES AND DISTRIBUTE THEM?

• The minutes should be taken by a medical or nursing member of staff, who is familiar with the terminology, and
can write insightful minutes.
• If a ward clerk is to write the minutes, then the clerk must be trained and supervised.
• Following the meeting, the minutes must be typed up (if required, support staff can help with the typing). They
must be checked and corrected by the meeting chairperson before distribution.
• The chairperson has responsibility for distribution of the minutes, but support staff may help with the process.
• Minutes must be distributed (usually by email) to all people on the attendance list within one week of the PNRM,
so that people responsible for tasks in the action plan can be reminded of what they are meant to do.
WHAT IS THE PLACE OF THE PPIP IN THE PERINATAL MEETING?

• If the PPIP database is up to date, the PPIP can be used to present the monthly key perinatal indicators with
trends. However, this can also be done without using PPIP.
• All hospitals must use PPIP as a quality improvement tool.
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• It is recommended that every six months a special PPIP meeting be held (this could be at the time of a
scheduled PNRM) to review the accumulated data from the previous six months, in particular the major causes
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of death and the most common avoidable factors in the facility. Trends in the key perinatal indicators compared
to the previous 6-month period can also be reviewed. An action plan should be made based on this data.
• Presenting this data every month will have limited value.
SHOULD PEOPLE RESPONSIBLE FOR POOR PERINATAL OUTCOMES BE IDENTIFIED AND COUNSELLED AT
THE PERINATAL REVIEW MEETING?
• The PNRM is not a forum for disciplinary action. It is primarily an educational meeting, and a meeting for setting
action plans to prevent deaths from similar causes.
• If there has been substandard or negligent practice that has led to a maternal or perinatal death, there should be
a meeting between the health workers concerned and their line managers in a private and confidential meeting
before the PNRM, and disciplinary action taken if appropriate.
• To maintain anonymity and confidentiality, names of patients and healthcare workers should not be included in
presentations. If copies are made of the patient charts for educational purposes at the meeting, all identifying
information for the patient and the health workers should be removed.
WHO IS CUSTODIAN OF THE ACTION PLAN?

• The quality assurance manager of the facility has a responsibility to follow-up on progress with implementing
the action plan in between meetings, however this role could be delegated by the top hospital management to
another suitable individual.
• This individual can follow-up to ensure that urgent actions get implemented without delay.
• Those named for specific responsibilities in the action plan should send progress reports during the month to
the quality assurance manager.
WHAT IS THE ROLE OF THE DCST IN THE FACILITY BASED PERINATAL MEETING?
• Ensure meetings happen in facilities.
• Ensure that the meeting follows the desired format.
• Ensure that a feedback process is in place, so that information and actions arising from the meeting are known
throughout the sub-district.
• Ensure that good action plans are developed and that follow-up on the actions occurs.
• DCSTs can add value by sharing their clinical expertise.
• Support and mentoring role.
• Must not take over the meeting – if PNRM are not happening or are poorly conducted, the DCST can chair one
meeting to demonstrate how a meeting should be run, can co-chair the next meeting, but by the third meeting
they must observe the PNRM being chaired by someone from the hospital and provide reflective feedback.
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Chapter 15
BASIC ULTRASOUND AT DISTRICT LEVEL

This chapter discusses the use of ultrasound for supporting pregnant woman,
including when they should be done, by whom and the various cases where an
ultrasound is indicated.
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CHAPTER 15: BASIC ULTRASOUND AT DISTRICT LEVEL

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Note: These guidelines are written for public sector doctors, midwives and sonographers who are
indemnified against medico-legal claims by the government. Recent changes in medical protection limits
private general practitioners, -radiographers, -sonographers and other private sector non-specialists to
the performance of very basic fetal dating scans during the first trimester only; and private sonographers
and -clinicians are advised to make sure that they are insured against medico-legal claims that can arise
from performing
DISTRICT LEVEL (LEVEL 1 SCAN)
• This level scan should preferably be performed by accredited ultrasonographers, but due to capacity constraints
can be done by radiographers without formal accreditation such as a National Diploma or B Tech degree,
midwives who completed a basic ultrasound course, or medical officers and family physicians at district
hospitals.
• At this level of scanning, one cannot expect to detect most of the serious foetal anomalies and patients should
be specifically informed about this limitation. The basic scan is therefore only suitable for patients at a low risk
for a foetal anomaly and should only be offered to these women.
• All pregnant women should preferably have access to one basic obstetric ultrasound examination, at 18-20
weeks gestation (if the infrastructure allows this) for the following:
○ to confirm an intra-uterine pregnancy
○ to determine foetal viability
○ to determine the number of foetusfoetuses
○ to determine the basic gestational age
○ to confirm the location of the placenta
○ to determine the amniotic fluid volume
Wherever possible, all patients should be referred to ultrasound as long as the SF measurement at booking is
< 24 cm. Patients who book very early should only be referred for the scan when the SF is approaching or at the level
of the umbilicus (this may be only weeks after the booking visit).
In addition, the following patients need to be referred to ultrasound at level 1:

• Unsure presenting part and/or breech at the 34 weeks visit - refer for ultrasound at 36 weeks gestation. If a
non-cephalic presentation confirmed at this 36 weeks visit - refer directly (within two days) to an experienced
doctor or to a specialist hospital for appropriate management (external cephalic version or planned elective
Caesarean section).
• Amniotic Fluid Index (AFI) or deepest amniotic fluid pool for suspected (clinical) postdates pregnancy (at
estimated 41-42 weeks with uncertain gestational age due to late booking).
• Clinical suspicion of multiple pregnancy at any gestation, with no previous ultrasound.
• Suspicion of intra-uterine foetal death.
REQUESTS FOR DOPPLER OF THE UMBILICAL ARTERY
The following patients can be referred for a Doppler test (in areas where this is available and if Doppler studies were
not already performed during the ultrasound visit); or to the appropriate specialist hospital, high risk or district specialist
outreach clinic (preferably to a unit with the appropriate ultrasound equipment) for evaluation by a specialist:
• SF growth <10th centile or no SF growth in six weeks
• all patients with hypertension in pregnancy (at 24 weeks or as soon as possible thereafter)
• previous unexplained mid-trimester or third trimester foetal loss (at 24 weeks or as soon as possible thereafter)
• diabetics at 24 weeks
Interpretation of umbilical artery Doppler (resistance index)

Manage the client according to the instructions from the high risk clinic. If there are no instructions with the Doppler
results, the suggested management is as follows:
• resistance Index (RI) < 75th centile - normal. Repeat only if the clinical condition changes
• RI 75th-95th centile: repeat the Doppler after two weeks (patient preferably needs to be managed at a high risk
clinic)
• RI > 95th centile - repeat the Doppler after one week (patient needs to be managed at a high risk clinic) and
arrange twice weekly for CTG as soon as viability is reached
• absent end diastolic volume (AEDV): refer for specialist/tertiary care as soon as the diagnosis is made; provided
there is no foetal distress in a clearly viable foetusfoetus (the foetusfoetus may need an urgent caesarean section
if at a regional health facility (if gestational age < 28 weeks - specialist at regional facility must discuss patient with
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tertiary unit before referral)
• reversed end-diastolic flow (REDV) - baby needs to be delivered by caesarean section within 24 hours if it is
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viable; if possible transfer mother before delivery to a specialist/tertiary unit
Any of the following abnormalities noted in the BASIC ultrasound should be scanned by an accredited sonographer
(National Diploma or more, at any level of care) or referred to a specialist obstetrician supported service for evaluation
(level two scan):
• multiple pregnancies- as soon as possible; to determine chorionicity
• discordant measurements- if there is (around 20 weeks) a discrepancy of 10 days or more between any of the
following: BPD, FL, AC; refer within one week
• placental location- if placenta < 2cm from the internal os at the initial scan, the person performing the scan
must make an appointment for a repeat scan at a specialist health facility at 32 weeks of gestation to determine
the exact placental location
• if there is decreased amniotic fluid (deepest pool < 3cm) or increased fluid (deepest pool > 8 cm) - refer
within one week
• any “abnormality” seen or suspected by a non-accredited practitioner must be referred to an accredited
sonographer or obstetric specialist with referral within one week; preferably discuss the specifics of the findings
by phone prior to referral
Any structural foetal anomalies (or any soft markers for anomalies) noted during the routine examination by an
accredited sonographer should be referred directly to a specialist health facility or maternal-foetal evaluation unit by the
sonographer doing the initial scan.
SCREENING FOR CONGENITAL ANOMALIES
Routine screening for structural and chromosomal foetal anomalies is not yet practical in the public sector in South
Africa. Targeted screening can be offered and the following pregnant women need referral to a specialist health facility
or a maternal foetal ultrasound unit:
All women with advanced maternal age (37 years or older with conception, but the age cut-off may vary due to
local protocols)
• Should be informed of their increased risk for trisomy 21 (T21).
• Should be offered referral to a genetic clinic, either at 11-13 weeks or as soon as possible from 16 or 18 weeks
onwards, up to an estimated gestation of 22 weeks and six days.
• Consenting women will be routinely offered a scan and formal genetic counseling and invasive testing to rule
out T21.
• Use the graph to show women the increase in risk for down syndrome according to her age.
Figure 15.1: Graph showing percentage risk for Down Sydrome in live births with increasing age
The following high-risk women must be referred for structural screening and management decision to
specialist hospitals
• Pre-gestational diabetes.
○ for Nuchal Translucency scan (NT) at 11-13 weeks
○ for foetal anomaly scan at 18-20 weeks
• Exposure to any teratogenic drugs, refer at 20 weeks.
• Previous history or family history of structural, chromosomal or genetic anomalies - at 11-13 weeks or as soon
as possible thereafter.
•
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Monochorionic twins – at 11-13 weeks or as soon as diagnosis is made and then every three weeks for follow-up.
Any other abnormal ultrasound findings - on diagnosis.
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To achieve all the above, it is essential that all unnecessary requests for ultrasound examinations are
identified and declined.
The following are usually not indications for referral to ultrasound at any level
• Patient’s request after 24 weeks, or for foetal sexing.
• Diagnosis of pregnancy.
• Vaginal bleeding with a negative pregnancy test.
• Amniotic Fluid Index (AFI) in suspected postdates less than 41 weeks.
ULTRASOUND DATING POLICY
When a BANC clinic has access to routine basic obstetric ultrasound for every client, the ultrasonographer can determine
the correct Gestational Age and Estimated Date of Delivery and record this on the antenatal card. If routine ultrasound
is not yet available, or the person “books” after 24 weeks, the health professional at the BANC clinic must do the
determination of gestational age according to the BANC protocols.
Certain menstrual history is defined as

• certain of the exact date of the first day of the Last Menstrual Period (LMP)
• normal LMP i.e. normal amount and duration of vaginal bleeding
• regular cycle of 25-31 days, no bleeding since LMP
• no hormonal contraception within three months prior to LMP
• in-vitro fertilisation treatment: use as “LMP” the date 16 days before the day of embryo transfer
First trimester: CRL, BPD, HC, AC

• Crown Rump Length (CRL) can be used for dating purposes up to a CRL of 80 mm, provided the measurement
is taken accurately with the foetusfoetus in a neutral position i.e. do not measure when the foetusfoetus is
stretched out or significantly curled up. Wait for the baby to move and re-measure when the foetal spine is only
slightly curved.
• If possible, perform full foetal biometry even in the first trimester and gestational age (GA) will be determined
by the composite GA of all measurements, rather than the CRL alone. Femur Length (FL) is not used for dating
since the reference ranges of the database are not accurate.
• If the first trimester Ultrasound (US) age is compatible with the menstrual age within a seven-day margin: accept
the LMP-expected date of delivery (EDD).
• If discrepancy of more than seven days: Find out whether an early pregnancy scan was done and compare the
results. Re-date according to US if scans both give a compatible EDD.
• If US smaller than LMP: Check the timing of the first pregnancy test. If the pregnancy test was positive shortly
after the first missed period: do not re-date from US but regard as early intrauterine growth restriction (possible
chromosomal abnormality) and review yourself in a few weeks. If no early pregnancy test was done: re-date
from CRL.
• If uncertain menstrual age or US larger than LMP: re-date from US but confirm at 18-22 weeks.
• Pregnancy following in-vitro fertilisation: never re-date from US.
Second trimester: BPD, HC, AC, FL (18-24w)

• Dating from US-measurements is only accurate if the different measurements are compatible with one another
and the foetusfoetus is normal. If there is significant discrepancy between head, abdomen or limbs, one should
search for abnormalities or signs of intra-uterine growth restriction (IUGR).
• Dating in the second trimester relies heavily on head measurements. Unless the head is significantly
dolichocephalic (long, flattened head), the biparietal diameter (BPD) and head circumference (HC) are used for
dating purposes. In case of dolichocephaly, only the HC is used.
• If all measurements are concordant, the US-gestational age is determined as the average gestational age from
all three or four parameters, provided “Chitty reference ranges” are used for all.
• If the biometry-age is compatible with certain menstrual age within a 14-day margin: accept LMP for EDD.
• If more than 14-day discrepancy with uncertain menstrual age: assign US-EDD if less than 24 weeks.
• If more than 14 day discrepancy with certain menstrual age:
○ if smaller but very early pregnancy test available: Consider as early IUGR and review in two to three weeks
and do Doppler
○ if smaller but no early pregnancy test: re-date from US if no signs of abnormality or asymmetry and normal
placenta and liquor
Third trimester (> 24 weeks) BPD, HC, AC, FL

• If > 24w: No accurate dating from US possible. If the patient is obese (Body Mass Index > 35 weeks) ultrasound
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dating can still be done up to 28 weeks.
• Look for signs of IUGR in the measurements and fetoplacental features. Dopplers should be done if any of
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these suggest IUGR in a more advanced gestation than what the measurements suggest.
• In the absence of any signs of IUGR, provisionally assign US-EDD but refer to the doctor for assigning a
working EDD and offer rescan for growth in two to three weeks if indicated.
• Results of informal earlier scans that were done by inexperienced and non-accredited staff may be ignored for
the purpose of allocating Expected Date of Delivery.
• NOTE: in any cases of uncertainty advice must be obtained telephonically from a foetal maternal unit or the
specialist hospital or the high risk clinic at the district hospital.
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Chapter 16
RESPONDING TO A MATERNAL DEATH AT A HEALTH CARE FACILITY

This chapter discusses the detailed steps to take to respond to a maternal death at a
health care facility over time, including who to inform and how notifications should
be done
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CHAPTER 16 : RESPONDING TO A MATERNAL DEATH AT A HEALTH CARE FACILITY
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The following action must be taken to respond to a maternal death at a healthcare facility.
IMMEDIATELY
• Inform most senior clinician on duty (e.g. consultant obstetrician on-call).

• Inform most senior nurse on duty (e.g. night matron).
• These senior staff must decide whether a post-mortem is required.
• Inform the family.
• Make arrangements for photocopying of the case file.
WITHIN 72 HOURS
• Inform top management of facility (CEO, Medical and Nursing Managers).

• Inform District Clinical Specialist Team (DCST).
• Hold a formal meeting to:
○ clarify all the facts about the case
○ make and record an initial action plan to prevent a recurrence
○ fill the maternal death notification form (Maternal Death Notification Form - draft)
• The meeting should include at a minimum:
○ all health care personnel who were responsible for the care of the patient around the time of death
(example: doctor on-call, including sessional doctors, nurses on duty in the relevant ward, doctors from
other disciplines where relevant)
○ the most senior clinician in the relevant disciplines at the facility (e.g. HOD or Clinical Manager for
obstetrics, but also for anaesthetics, medicine etc where relevant)
○ the assistant nurse manager for maternity and for other sections where relevant to the case (e.g. theatre,
medical wards and casualty)
○ at least one of the top management of the facility
○ relevant member(s) of the DCST (includes obstetric specialist, advanced midwife, family physician, PHC
nurse, and anaesthetist)
• Arrange a meeting to discuss the case with the family (an experienced senior doctor and nurse who know the
case well should be present).
• Debriefing / supportive counselling should be conducted by senior staff for any members of staff closely
involved in the case who feel mentally effected by the death.
WITHIN ONE MONTH
• All relevant documentation related to the case should have been compiled. This includes notes from other
institutions who managed the patient during pregnancy (the patient may have been referred to the facility where
she died), all theatre notes, ICU notes, investigation results and any provisional post-mortem report.
• Feedback should have been given to other facilities who may have managed the patient during her pregnancy
(e.g. PHC clinics who conducted the antenatal care or District hospital that referred to the regional hospital. It is
preferable to invite members of the referring hospital /clinic to the meeting).
• The case should have been discussed at a scheduled monthly perinatal mortality meeting, using the case to
highlight any lessons learnt, and to give feedback on progress with the initial action plan. Representatives from
all the referring clinics should be present at a hospital’s perinatal meeting. The DCST should also be represented.
Preliminary information of post mortem if done should be obtained if at all possible.
• Following the discussions at the PNMM, any additions to the action plan and to the filling of the maternal death
notification form (MDNF) can be finalized. The MDNF must be signed by the head of the maternity unit.
• A copy of all documentation related to the case, together with the completed MDNF must be delivered to the
Provincial MCWH Office, for the purposes of the Confidential Enquiries into Maternal Death.
WITHIN THREE MONTHS
• The case should be presented at the District Perinatal Meeting. At this forum, the focus should be on feedback
regarding the implementation of the action plan drawn up at the facility in response to the maternal death.
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Chapter 17
ROUTINE POSTNATAL CARE

This chapter discusses the various steps in postnatal care, including potential
emergencies and how to prevent and treat them.
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OBJECTIVES
The objectives are to manage the normal psychological and physical changes that occur in the first days after delivery;
to assist, counsel and provide advice, and to screen for and detect problems that threaten the health of the mother and
baby.
POSTNATAL CARE AFTER NORMAL VAGINAL DELIVERY
• Do not separate the mother and her baby unless one of them requires special or intensive care.
• On the mother’s arrival in the postnatal ward, check the BP, the heart rate, that the uterus is firmly contracted
and that there is no evidence of active vaginal bleeding.
• Consider and note any problems that the women may have had during the antenatal period and during labour.
• Ensure that the mother is mobile and can pass urine.
• Prescribe paracetamol one gram orally if the mother complains of mild pain.
• Counsel on infant feeding, contraception, and self-care in the puerperium.
• Ensure that mothers are offered the support necessary to acquire the skills of correct positioning and
attachment of their infants for optimal breastfeeding. Explain the necessary techniques to the mother, thereby
helping her to acquire the skill for herself.
• Mothers who have decided not to breastfeed after counselling and education should be given information on
age specific types of infant formula to purchase and shown how to prepare and use formula safely
• Ensure four hourly BP, heart rate, temperature, and pad check assessments.
• Call a senior midwife or doctor if there are abnormalities: consider transfer from a CHC to hospital.
Discharge from clinic or hospital is permissible 6 hours after delivery provided that:
• there are no medical, surgical or obstetric problems that require attention
• the mother looks and feels well
• there is no evidence of anaemia
• the heart rate (< 100/min), respiratory rate (< 20/minute) temperature (< 37.5 °C) and the blood pressure are all
normal
• there is no unexpected uterine tenderness
• there is no active vaginal bleeding
• the woman is mobile and has passed urine normally
• there is no excessive pain in the abdomen or perineum
• infant feeding has been explained and demonstrated
• information where to get continued infant feeding support if she needs it after discharge
• contraception has been discussed and provided
• all blood results – Hb, syphilis, Rhesus group, and HIV – are recorded and appropriate actions taken
• a discharge summary form has been completed appropriately
Self-care of healing episiotomy or perineal tear

• Advise on perineal hygiene: sitz baths twice daily in warm water (salt or antiseptics not essential).
• Advise that the sutures will absorb and fall out spontaneously (check that the sutures used are absorbable).
• Pain can be managed with ice packs and/or oral paracetamol one gram orally four times daily.
• The mother should return to the clinic if pain worsens or does not respond to simple measures.
• First and second degree tears heal faster than episiotomies.
• With episiotomy, it may take up to one month before sexual intercourse can resume.
The postnatal visit at three to six days

All mothers should attend their local clinic three to six days after normal delivery, for check-up of themselves and their
babies. Essential elements of the woman’s check-up are as follows:
• any orders or special concerns noted on the discharge summary
• check temperature, heart rate, blood pressure, respiratory rate
• palpate the abdomen and uterus for tenderness
• examine the legs for evidence of thrombosis
• check for vaginal bleeding and offensive vaginal discharge
• check breasts and nipples for any problems
• assess the baby’s condition
• counsel and advise on self-care, mood problems, infant care and feeding, and the six weeks follow-up
• call a senior midwife or doctor if there are abnormalities: consider transfer from a CHC to hospital
The postnatal visit at six weeks
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Most activities at the sixth weeks visit relate to care of the baby (HIV, vaccinations, weighing, feeding). When attending
to the mother:
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• assess general well-being of the mother
• check for pallor and measure the BP and heart rate
• do bedside Hb test, if low send off full blood count and get advice from a specialist
• review contraception choices: an intrauterine device may be inserted at this time /alternately implants may be
considered
• counsel on any problems
• remind HIV-negative breastfeeding mothers to return at three months for HIV testing
POSTNATAL CARE AFTER CAESAREAN DELIVERY
• Do not separate the mother and her baby unless one of them requires special or intensive care.
• On the mother’s arrival in the postnatal ward, check BP, heart rate, uterine contraction, wound dressing and pad
for bleeding.
• Check the caesarean section notes for indication and complications, and ensure all surgeon’s and
anaesthetists’ orders and prescriptions are clearly understood and followed.
• Check BP, heart rate, pad checks:
○ half hourly for two hours
○ hourly for four hours
○ two hourly for six hours
○ four hourly until the mother is discharged
• Check temperature and urine output four hourly.
• Remove the urinary catheter after six hours, unless there is a note from the surgeon to keep the catheter in.
• Allow the woman to be up and about as soon as she feels strong enough.
• After uncomplicated caesarean section, give oral fluids and a light meal as soon as the woman feels hungry.
• Call a doctor if there are abnormalities: consider transfer from a CHC to hospital.
• A doctor’s ward round must be done at least once daily.
• The mother may be discharged on the second day (36-48 hours) after an uncomplicated caesarean section,
if all observations are normal, as above for vaginal delivery. In particular, women with a heart rate > 100/
min or respiratory rate > 20/minute require thorough assessment and investigation, and should not be
discharged.
• Women with risk factors for infection (HIV infection, prolonged labour, prolonged rupture of membranes,
chorioamnionitis, or caesarean section in the second stage) may need to be kept in hospital on antibiotics for
three to five days.
• Write a clear discharge summary with orders for removal of sutures and follow-up visits.
• The six-week postnatal visit will be the same as after normal vaginal delivery.
ABNORMALITIES OF THE PUERPERIUM
This section describes postnatal problems occurring after discharge from the labour ward or operating theatre.
Frequently, women will present with secondary postpartum haemorrhage or puerperal sepsis after discharge from
CHC or hospital.
SECONDARY POSTPARTUM HAEMORRHAGE

This is passage of fresh blood or clots from the vagina more than 24 hours after delivery. Common causes are uterine
sub-involution, retained products of conception, and wound breakdown or haematomas.
Emergency management
• Assess general condition, especially consciousness, temperature, colour, BP, heart rate and respiratory rate.
• Resuscitate if necessary as for management of primary postpartum haemorrhage.
• Take blood for FBC and cross-match.
• Give oxytocin 10 units intramuscularly as a single dose.
• Add oxytocin 20 units to one litre Ringer-Lactate and run at 125 mL/hour.
• Consider adding Syntometrine one ampoule IM or ergometrine 0.5 mg IM as a single dose unless the mother is
hypertensive or has cardiac disease.
• Admit the patient or transfer from CHC to hospital.
• Look for and treat the cause of bleeding:
○ if there is evidence of puerperal sepsis, proceed as for puerperal sepsis (section below).
○ on vaginal examination, feel for retained products through the cervix, and do a trans-abdominal ultrasound
scan if no products are felt. If products are retained, arrange for evacuation in theatre.
○ examine carefully for secondary haemorrhage from healing lacerations or wounds, and treat appropriately.
○ with no evidence of puerperal sepsis or wound breakdown, assume sub-involution and continue with
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oxytocin infusion. Add oral antibiotics: amoxicillin 500 mg orally three times daily and metronidazole 400
milligram orally three times daily.
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With no evidence of puerperal sepsis or wound breakdown, assume sub-involution and continue with oxytocin
infusion. Add oral antibiotics: amoxicillin 500 mg orally 3 times daily and metronidazole 400 mg orally three
times daily.
• Severe haemorrhage that does not respond to the above measures may require examination in theatre, and
even laparotomy and hysterectomy, ideally at specialist referral level.
PUERPERAL SEPSIS
This is infection of the upper genital tract after delivery, which may involve the endometrium (decidua), myometrium,
operative incisions, pelvic peritoneum or the entire peritoneal cavity. Severe puerperal sepsis is life threatening and its
early signs can easily be missed because of atypical presentation or incomplete clinical assessment on admission.
The most common presentation of puerperal sepsis is lower abdominal pain and/or abnormal vaginal discharge during
the postpartum period. Additional symptoms (e.g. fever, weakness, vaginal bleeding) are frequent.
Clinical risk factors for puerperal sepsis

• Caesarean delivery
• Prolonged labour
• Frequent vaginal examinations in labour
• Prolonged rupture of membranes
• Traumatic delivery
• Antenatal anaemia
• Poor immunity – HIV infection, diabetes mellitus or chronic use of corticosteroids
• Extensive vulvar warts
• Retained placenta or products of conception
MILD PUERPERAL SEPSIS

Clinical features include mild uterine tenderness without evidence of peritonitis, heart rate < 100/minute, temperature
< 37.5 degrees C, and offensive lochia (discharge).
Management
• On vaginal examination, exclude retained products of conception by feeling for retained products through the
cervix. If products are retained, arrange for evacuation in theatre with IV antibiotic cover and oxytocics, or
transfer from CHC to hospital.
• Give amoxicillin 500 milligram three times daily orally and metronidazole 400 milligram three times daily orally
for five days.
• If the patient is allergic to penicillin, give erythromycin 500mgfour times daily orally instead of amoxicillin.
• Encourage adequate intake of oral fluids.
• Follow up for reassessment in 36-48 hours.
• If not improving, admit and transfer to specialist level.
SEVERE PUERPERAL SEPSIS

Clinical features include temperature ≥37.5 degrees C and a heart rate ≥100/min in the presence (not always) of
offensive lochia and uterine/abdominal tenderness. Consider other causes of infection, e.g. meningitis, TB, pneumonia.
After initial assessment and emergency management, patients with severe puerperal sepsis should be transferred to
specialist level.
Emergency management
• Take a full but relevant history of the pregnancy and delivery with reference to documentation if available.
• Do a full physical examination, with special attention to consciousness, temperature, heart rate, respiratory rate,
colour, chest, abdomen and vaginal examination.
• Watch out for signs of septic shock and proceed as below, with additional measures for septic shock (below).
• Evaluate organ systems clinically: big five (cerebral, cardiovascular, respiratory, liver and kidney), forgotten four
(haematological, immune, endocrine, musculoskeletal, and core one (urogenital).
• Take blood for FBC, U&E and culture.
• Insert an intravenous line with Ringer-Lactate, and run at 125-240 mL/hour.
• Insert a urinary catheter.
• Ensure that antibiotics are given within one hour of presentation: start with ampicillin one to two grams IV,
gentamicin six mg/kg mg IV, and metronidazole 400 mg orally (or 500 mg IV if vomiting).
• Monitor heart rate, blood pressure and urine output hourly.
• Transfer from CHC or district hospital to specialist level.
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• Treat for septic shock if the systolic BP is less than 90 mmHg with a heart rate ≥100/minute in the presence of
signs of infection.
• Give a rapid infusion of Ringer-Lactate one to two litres (20 mL/kg).
• Observe BP, heart rate and respiratory rate half hourly, and oxygen saturation continuously (if equipment
available).
• Give oxygen by mask.
• Aim for systolic BP ≥ 100 mmHg, or mean arterial BP ≥ 65 mmHg, respiratory rate < 30/minute, oxygen
saturation > 90 per cent, and haematocrit > 30 per cent.
• Consider adding adrenalin and emergency blood transfusion.
• Transfer from a district hospital to a specialist health facility with full documentation of treatment given, as soon
as the patient is reasonably stable.
CAESAREAN DELIVERY WOUND SEPSIS

This usually presents four to ten days after CD. The wound is tender and indurated, and pus may be expressed from
the suture line.
Assessment and management

• Assess for mild or severe wound sepsis, including full physical and gynaecological examination, and manage as
above, including transfer from CHC to hospital, or to specialist care if necessary.
• Open the wound and remove sutures from the skin and subcutaneous tissue.
• Aspirate tender or fluctuant areas with a needle and syringe, and send blood or pus for MC&S. Do not send pus
swabs.
• Subcutaneous abscesses may be drained using local and/or opiate analgesia.
• If the wound is frankly necrotic or the surrounding skin has areas of blistering or gangrene, treat for severe
sepsis and transfer to specialist care.
• Inspect the depth of the wound: if the rectus sheath is not intact, transfer to a specialist health facility.
• Add cloxacillin to the antibiotic regimen.
• Order wound dressings as appropriate for the dressing method used.
Figure 17.1 below shows the management of puerperal sepsis.

Lower abdominal pain
Abnormal wound or
vaginal discharge
Symptoms of infection
Full clinical assessment

Vital signs
Exclude other source of
infection
Exclude retained
products
Heart rate ≥100/minute

Heart rate <100/min
Temperature ≥37.5
Temperature <37.5
degrees C
degrees C
Evidence of peritonitis
Mild uterine tenderness
Wound necrosis or sheath
disruption
Mild puerperal sepsis

Oral antibiotics
Review in 36-48 hours Severe puerperal sepsis
IV antibiotics within 1 hour
IV fluids and catheter
Stabilise if in septic shock
Transfer to specialist care
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SERVICES
1. Equipment
Level one Level two Level three
A B C D E F
Mobile services Day clinic (no 24 24 hour clinic & District hospital Regional hospital Tertiary / quaternary
hour service): community health hospital
centres
• BP machine and As for A + As for B + As for C + As for D + • As for E
different size cuffs
• Working scale for • Haemoglobino-me- • Hand held Doppler • CTG • Forceps
both adults and ter • Bedpans • Ultrasound scan • Facilities for major
neonate • Glucometer • Delivery pack • Oxygen source • Surgery (e.g hyster-
• Tape measure • Hand held Doppler • Episiotomy / tears (portable cylinder or ectomy)
• Thermometer • Emergency delivery • repair set central wall supply) • High care and ICU
• Adult stethoscope pack • Fixed / mobile together with mask • Blood bank
• Fetal stethoscope • Watch or clock with suction or nasal cannula,
• Haemoglobino- second hand that • Vacuum extractors tubing and flow
meter can be seen easily and cups? (for use meter
• Good light source • Refrigerator or cold by advanced mid- • Intravenous infusion
• Vaginal specula of box (for storage of wives) pumps
• different sizes drugs and vaccines) • Equipments for ne- • Functioning theatre
• Cold box (for stor- • Equipment for onatal resuscitation with equipment
age of drugs and IUCD insertion and - mucous • Equipment for re-
vaccines) removal • extractor and infant suscitation of adults
• Effective communi- face mask including defibrillator
cation system • Overhead radiant • Equipments for neo-
• Instrument & For- • Heater natal resuscitation
ceps sterilizer • Equipment for adult • Craniotomy equip-
• Jar for forceps • rescuscitation? ment?
• Dressing forceps • Adult ventilator • Theatre packs for
• Kidney basins bag and mask and C/S,minilaparatomy
• Sponge bowls Mouth gag evacuation of the
• Scissors uterus
• Surgeon’s hand • X-Ray facilities
brush • Laboratory facilities
• Heat source
2. Drugs and supplies

Level two Level three
A B C D E F
centres
• Urine dipstix As for A + As for B + As for C + As for D + As for E
• Intravenous infusion
sets • Oxygen • Drugs for resuscita- • Emergency blood • Antidiabetic drugs
• Intravenous fluids • Drugs for obstetric tion of neonates • Drugs to manage • Anti-coagulants and
• Venepuncture • emergencies • Drugs for resuscita- • hypertension, antidote
supplies • IV administration tion of adults diabetes and other
• Alcohol/Betadine / sets • Urine catheters and pregnancy-related
Savlon • IV solutions: bags / medical complica-
• Gloves – exam- • Ringer’s lactate, • Oxytocic drugs for tions
ination & utility / normal saline, active management • Induction of labour
heavy-duty house- glucose of third stage of drugs
hold gloves for • On site testing kits labour • Tubal ligation
cleaning for: pregnancy, Rh • Local anaesthetic facilities
• Puncture-proof- D syplillis, HIV, urine • Suture needles and • Insertion of IUCD
container for sharps alysis material facilities
disposal • Supplies for drawing • Antibiotics • nti-hypertensive
• Disinfectant blood - (tourni- • Tocolytics drugs
• Chlorine for making quets, syringes • Analgesia • Diuretics
decontami-nation and needles,tubes, • Anti-allergy drugs
solution labels)
• Condoms - male & • Soap at all sinks
female • Drugs for obstetric
• Hormonal con- emergencies -
traception pills & MgSO4, tocolytics,
injectables oxytocic, antibiotics
• Vaccines for antimalaria (in af-
immunisation (both fected provinces)
mothers & children)
• Haematinics - Fe,
folate
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• Supplies to take pap
smear
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Level one Level two Level three
A B C D E F
centres
• Appropriate docu- As for A + As for B + As for C + As for D + • As for E
menta tion sheets
for narrative notes, • Referral forms • Maternity case
etc. • Laboratory request records
• Antenatal cards forms • Delivery register
(Mother -Ba- • Postnatal register referrals
by-Package)
• Antenatal register
(EmOC)
• Guidelines (EDL)
APPENDIX 1: ANTENATAL CORTICOSTEROID THERAPY AT DISTRICT LEVEL FOR REDUCTION OF

NEONATAL MORBIDITY AND MORTALITY.
INTRODUCTION
Spontaneous preterm labour is the second most important primary cause of obstetric death in South Africa and five
out of every 1 000 babies born will die from complications of prematurity(1). There are several interventions that can
reduce morbidity and mortality from preterm birth and this can be delivered during antenatal care, labour and during
care of the preterm infant after birth(2). However, the most beneficial interventions are those that aim to improve the
outcome of preterm babies when a preterm delivery is inevitable and of these, antenatal corticosteroids, magnesium
for neuroprotection and antibiotic prophylaxis for preterm rupture of the membranes (PROM) are the most valuable(3).
This guideline will focus on the use of steroids for the reduction of complications of prematurity at district level.
The use of steroids to enhance foetal lung maturity is associated with a 30 per cent reduction in death. A systematic review
and meta-analysis(4) has found that treatment with antenatal corticosteroids is associated with an overall reduction in:
• Respiratory Distress Syndrome
• Intraventricular Haemorrhage
• Necrotising Enterocolitis
• Need for respiratory support
• Intensive care admissions
• Systemic infections in the first 48 hours of life
Steroid administration was NOT associated with changes in the rates of maternal death, maternal infection, foetal death,
neonatal chronic lung disease or birthweight. These trials were mostly conducted in high- and middle income countries.
Results from a large trial conducted in a resource poor setting shows less benefit, with a poorer outcomes when used
at later gestations (steroid use after 34 weeks) and an increase in maternal sepsis.(5)
The WHO Recommendations on Interventions to Improve Preterm Birth Outcomes states that antenatal corticosteroids
to enhance lung maturity should only be used for a gestational age between 24 and 34 weeks, and only where the
following conditions can be met(6):
1. The ability to accurately assess gestational age

2. Preterm birth is considered to be imminent.
3. No clinical evidence of maternal infection
4. Adequate childbirth care is available (including the capacity to recognize and safely manage preterm labour
and birth)
5. Adequate care is available for preterm new-borns (e.g. resuscitation, thermal care Kangaroo Mother Care,
adequate feeding support, treatment of infection, safe oxygen use)
The United Nations Commission on Life-Saving Commodities(7) adds the availability of reliable, timely and
appropriate identification and treatment of maternal infection as another pre-requisite for steroid use.
TERMINOLOGY
Some recommendations can be made with more certainty than others. This guideline is based on the recommendations
of the World Health Organization(6) and makes a recommendation based on the trade-off between the benefits and
harms of an intervention. The terminology used in this guideline denotes the certainty with which the recommendation
is made (the strength of the recommendation, based on the available evidence)(8). For all recommendations, there
should be a thorough discussion with the patient regarding the risks and benefits of the interventions, and their values
and preferences. Such discussion aims to help them to reach a fully informed decision.
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Should (or should not) A 'strong' recommendation
‘Offer’ For the vast majority of patients, an intervention will do more good than harm, and be cost effective
'Consider' An intervention will do more good than harm for most patients, and be cost effective, but other options may be
similarly cost effective.
‘Discuss’ Depends on the patient's values and preferences; the healthcare professional should spend more time considering
and discussing the options with the patient
WHICH STEROID?
Betamethasone and Dexamethasone are the only two effective and safe corticosteroids to be used during the antenatal
period. Both these drugs are identical in biologic activity and readily cross the placenta. No definitive evidence supports
a clinical preference for either drug based on the balance of efficacy and safety outcomes, although the relative risk
reduction in respiratory distress syndrome and early neonatal death is somewhat better for betamethasone than for
dexamethasone (0.56 vs 0.80)(4). Dexamethasone is more easily available and cheaper(9).
There are different preparations available, depending on the current tender, so check the concentration before
administration:
• Betamethasone 3mg/ml (1ml Ampoule)
• Betamethasone 4mg/ml (1ml Ampoule)
• Dexamethasone 4mg/ml (1ml Ampoule)
LIMITS OF VIABILITY / MINIMUM ESSENTIAL STANDARD OF CARE

“Viability” is historically defined as that gestational age where 50 per cent of babies born will have a reasonable chance
of survival. Viability is defined differently in different socioeconomic environments; in high income countries the threshold
of viability is defined at 24-25 weeks gestational age. There is not currently a worldwide, uniform gestational age that
defines viability. This variation is driven by resource constraints that limit the available package of care (notably, neonatal
intensive care) necessary to ensure survival of such preterm babies. These economic constraints are applicable to
a South African community as it is an issue of fairness that scarce resources are distributed fairly among competing
individuals.
In South Africa, in the best case public sector scenario (tertiary hospitals), survival is <50 per cent for babies born with
birth weight 800-899g and worse for birthweights below 800g. About 50 per cent of babies born at a birth weight of 900g
and managed under ideal conditions will survive.
Birth weight Survival rate Hospital

800-899g 37% Chris Hani Baragwanath(10)
800-899g 38% Charlotte Maxeke Johannesburg Academic
Hospital 2006-2010 (11)
800-899g 28% Charlotte Maxeke Johannesburg Academic
Hospital 2006-2007 (12)
<750 g 56% Tygerberg Hospital 2007-2009(13)
RECOMMENDATIONS
28 WEEKS 0 DAYS-33 WEEKS 6 DAYS
A baby born at 28 weeks of sure gestation (AND a minimum estimated foetal weight (EFW) of at least 900g), may have
a reasonable chance of survival in a South African setting. This is the gestational age where all foetusfoetuses and
neonates should at least be offered active management (including but not limited to foetal monitoring (cardiotocography
or CTG); antenatal corticosteroids; antenatal magnesium sulphate (MgSO4) for neuroprotection, appropriate antibiotic
administration, neonatal resuscitation, and continuous positive airway pressure ventilation (CPAP) where available).
26 WEEKS 0 DAYS-27 WEEKS 6 DAYS

At 26 and 27 weeks (or a birth weight <900g) the chance for intact survival is extremely poor. This is the gestational
age where foetusfoetuses and neonate may have the option of receiving active management where available (including
but not limited to foetal monitoring (CTG); antenatal corticosteroids; antenatal MgSO4 for neuroprotection, appropriate
antibiotic administration and neonatal resuscitation). This care will only be provided to parents who accept the risks of
potential caesarean delivery on the understanding that full intensive neonatal care may not be available. Such cases
should be managed on an individualised basis involving a multidisciplinary team ideally consisting of neonatologists and
obstetricians and thus will mainly be available at large regional or tertiary hospitals. Parents who decline this approach
on the basis of maternal risk associated with caesarean delivery (CD), will have all necessary care provided with the
exception of foetal heart rate monitoring and CD will not be considered for foetal indications. Consider giving steroids at
this gestation before referral.
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In these cases suppression of labour can still be attempted (25 weeks and above), and steroid administration can be
discussed with the parents.
<25 WEEKS
Below 25 weeks, attempts at resuscitation will mostly be futile in the current setting; and intact survival is rare; thus at
24 weeks six days or less (<25 weeks) [OR if the gestation is unknown and ultrasound cannot be done in time, a birth
weight of ≤ 500g] no active intervention will routinely be offered. Do not administer steroids in these early gestations.
→These cut-offs refer to pregnancies where delivery is indicated for maternal reasons, or where delivery is imminent.
All attempts should still be made to prolong the gestation to a viable age, if at all possible and where the maternal
condition allows for it.
COMFORT CARE
The World Health Organization (WHO) defines live birth as “the complete expulsion or extraction from the mother of
a product of conception that shows signs of beating heart, breathing movements, pulsation of the umbilical cord, and
movements of voluntarily muscles.” Each product of such a birth is considered a live born irrespective of the duration
of pregnancy(14). A baby born alive but below the limits for active intervention must receive comfort care and NOT be
placed in a fridge or a sluice room. Explain the situation in detail to the parents; including the fact that the baby may be
alive and gasping for several hours. Keep the baby warm by either putting him/her in the KMC position or by placing him/
her in a polyethylene bag immediately after delivery without drying first.
Comfort care has many challenges, including the inability to adequately treat pain in the dying infant, the emotional
and spiritual distress of the family, inadequate communication between caregivers and the family and the emotional
and moral distress of the staff(15).
DETERMINING GESTATION
In cases of pre-term labour, pre-labour rupture of the membranes and where preterm delivery is planned due to
complications such as pre-eclampsia, care must be taken in assessing the gestational age as accurately as possible, as
the gestational age determines the management. This is best achieved by an early ultrasound scan (before 24 weeks’
gestation), which should be considered together with the gestational age according to dates (last menstrual period
(LMP)). If there is no early scan, then the assessment is more difficult and all other evidence of gestational age, such
as LMP, first SFH measurement and any late scan findings should be considered. All relevant information should be
discussed with the specialist hospital, so that appropriate management can be planned together according to the best
estimate of the gestational age.
FOR SETTINGS WHERE THERE IS ACCESS TO COMPETENT OBSTETRIC ULTRASOUND ASSESSMENT

Women who book for pregnancy should ideally be referred for a gestational age ultrasound wherever feasible. Use the
ultrasound to determine the gestational age.
The 50th centile for birthweight at 28 weeks is 1150g (13) and at 27 weeks is 950g(16). When accurate gestation is
known, use the lower cut-off for estimated foetal weight (EFW) as 900g to be considered for active management.
A late ultrasound can give an estimate of the gestation but it should always be regarded as approximate. The dating is
more reliable when the average of the bi-parietal diameter (BPD), head circumference (HC), abdominal circumference
(AC) AND femur length (FL) is used and ALL the following criteria are met:
• views are adequate and standardised planes were obtained
• measurements are concordant (no asymmetric growth of small AC compared to HC:– P95 for HC/AC at 24w is
1.26; at 26 w is 1.24; at 28w is 1.22)
• there is not advanced placental maturation (extensive calcification, Granum II or III)
• there is a normal amniotic fluid volume (deepest vertical pool > 3cm)
• there is no underlying maternal disease (e.g. pre-eclampsia, severe chronic functional impairment) that could
result in a growth restricted foetus
When the gestational age is uncertain, the decision regarding full active intervention is based NOT on the
estimated foetal weight but on an ultrasound-based average gestational age of 28 weeks zero days or more.
Only if the measurements are discordant or the findings is suggestive of intra-uterine growth restriction, use the
estimated foetal weight as the criterion for active intervention (900 grams or more according to the Hadlock formula).
If it is not possible to do all the required measurements, use the BPD to calculate the gestational age (or HC if there is
dolichocephaly) in the interim; until a more senior or formal assessment can be done.
NO EARLY ULTRASOUND
In the absence of accurate gestational age (early booking and ultrasound determination before 24 weeks), an attempt
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must be made to do an ultrasound on clinical presentation. In a local setting, where patients present late for antenatal
care and obesity are common; and the exact date of the last menstrual period is unreliable, dating with ultrasound is
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significantly better than a reliance on clinical methods, even when certain dates appeared to be compatible with the
fundal height.(17)
NO ULTRASOUND SERVICE AVAILABLE

When there is no ultrasound machine or competent sonographer available to determine gestational age, and it is not
possible to refer a women in time for ultrasound, do a clinical weight estimation and offer steroids (when indicated) for a
clinical foetal weight of 1 000g-2 000g. Discuss further management with the local specialist centre.
If a baby is born without an accurate gestational age calculation, use a minimum birth weight of 900g as the lower limit
to offer the essential preterm package of care (this includes Help Babies Breath, management of the Small and Sick
Neonate, Expressed Breast Milk, Kangaroo Mother Care, Continuous Positive Airway Pressure). If in doubt, discuss
further management with the local specialist centre.
PROTOCOL FOR THE ADMINISTRATION OF ANTENATAL STEROIDS

POPULATION:
• Women with established preterm labour between 26 weeks zero days and 33 weeks six days.
• Women with preterm prelabour rupture of the membranes (PPROM), between 26-34 weeks.
• Women with an indication for delivery between 26 weeks zero days and 33 weeks six days (e.g. severe
pre- eclampsia).
STAFF
Antenatal corticosteroids must be prescribed by a doctor.
• A midwife that works in a primary care clinic that refers to a hospital where neonatal facilities are present can
administer the first dose before referral, after consultation with the doctor on call at that hospital.
• A Professional Nurse or midwife working in a maternity section of a hospital can administer steroids after
prescription by a doctor.
DRUG AND DOSE

Dexamethasone eight milligram intramuscularly eight hourly (24 mg in total). Administer intramuscularly in the deltoid
muscle.
Alternative drug:
Betamethasone twelve milligram intramuscularly and repeat in 24 hours (24 mg in total).
The positive effect of steroids is already present within the first few hours after the first injection and the optimal effect
is 48 hours after the first injection.
EXTRA PRE-CAUTIONS
• There are increased dangers of giving antenatal steroids to women with diabetes as the steroids may interfere
with blood sugar control. If antenatal steroids are being considered for diabetics, for the indications above, they
should be admitted to a regional or tertiary hospital first.
• Women with severe pre-eclampsia/eclampsia may develop pulmonary edema with steroid use. Do not
administer when a woman is tachypnoeic (respiratory rate >24/minute) unless she is adequately assessed by a
doctor.
• Women who receive an intravenous salbutamol infusion for suppression of preterm labour may develop
pulmonary edema with steroid use. If a decision is made to use tocolytics, then nifedipine should be used.
• There is an increased incidence of post-partum sepsis in women who received steroids. Ensure adequate follow
up post-delivery and inform all women of the warning signs of early sepsis.
CONTRA-INDICATIONS
• Overt/clinical chorio-amnionitis
• Pulmonary oedema
• Active pulmonary tuberculosis
• CI for steroids in general (herpes keratitis, peptic ulcer disease)
• Uncontrolled diabetes
NOT INDICATED:
• Elective Caesarean Delivery (CD) at 35 weeks or more but before 39 weeks. Rather schedule elective
caesarean delivery for 39 weeks.
• Do not offer steroids after 34 weeks of gestation, as there is more evidence of harm than benefit.
• Do not use steroids <25 weeks
REPEAT COURSE OF ANTENATAL CORTICOSTEROIDS
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A single repeat dose (12mg) of antenatal corticosteroid is recommended if preterm birth does not occur within seven
days after the initial dose, AND a subsequent clinical assessment demonstrates that there is a high risk of preterm
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MANAGEMENT OF IMMINENT EXTREME PRETERM DELIVERY
In cases where an extreme preterm delivery is anticipated (< 28 weeks) outside of a tertiary hospital (not enough time
for intra-partum referral).
• Discuss the management with a specialist centre and follow their advice. This may include the following:
○ administer steroids
○ offer magnesium sulphate for neuroprotection (4g in 200ml saline infused over 20-30 minutes, followed by
either 1g/hour iv infusion for 24 hours; or 5g intramuscularly in each buttock followed by 5g IM 4 hourly ); if
it is not contra-indicated. Use the same observation chart and pre-cautions as for MgSO4 for pre-eclampsia
○ give Ampicillin two gram intravenous four hourly until delivery for group B beta haemolytic streptococcus
prophylaxis (18)
○ inform the doctor on call to be present at birth
○ do an atraumatic vaginal delivery as far as possible
○ evaluate the baby at birth:
• offer active intervention according to the weight categories in this guideline, with appropriate referral
after birth if possible
• if there are no signs of life, or only gasping- explain the situation to the parents, and administer comfort
care
• keep all pre-term <1000g infants warm by putting the body of the baby (not the head) in a polyethylene
bag immediately after delivery without drying first.
Further reading
• For protocols on the management of preterm labour, refer to the National Maternity Care Guidelines 2015
version.
• The WHO recommendations on interventions to improve birth outcomes (reference nr 6 below) for more guid-
ance on interventions such as wrapping of the baby after birth, neuroprotection and antibiotic prophylaxis.
REFERENCES
1. Saving Babies [Internet]. Perinatal Problem Identification Program. [cited 2015 Sep 19]. Available from: http://www.
ppip.co.za/saving-babies/
2. Iams JD, Romero R, Culhane JF, Goldenberg RL. Primary, secondary, and tertiary interventions to reduce the
morbidity and mortality of preterm birth. Lancet Lond Engl. 2008 Jan 12;371(9607):164–75.
3. Requejo J, Merialdi M, Althabe F, Keller M, Katz J, Menon R. Born Too Soon: Care during pregnancy and childbirth to
reduce preterm deliveries and improve health outcomes of the preterm baby. Reprod Health. 2013 Nov 25;10(Suppl
1):S4.
4. Roberts D, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm
birth. In: The Cochrane Collaboration, editor. Cochrane Database of Systematic Reviews [Internet]. Chichester, UK:
John Wiley & Sons, Ltd; 2006 [cited 2015 Aug 5]. Available from: http://doi.wiley.com/10.1002/14651858.CD004454.
pub2
5. Althabe F, Belizán JM, McClure EM, Hemingway-Foday J, Berrueta M, Mazzoni A, et al. A population-based,
multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of
neonatal mortality due to preterm birth in low-income and middle-income countries: the ACT cluster-randomised
trial. The Lancet. 2015 Feb;385(9968):629–39.
6. WHO | WHO recommendations on interventions to improve preterm birth outcomes [Internet]. WHO. [cited 2015
Sep 6]. Available from: http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/preterm-birth-
guidelines/en/
7. Notes on the Antenatal Corticosteroids Trial (ACT) [Internet]. 2014 [cited 2015 Aug 5]. Available from: http://www.
healthynewbornnetwork.org/resource/notes-antenatal-corticosteroids-trial-act
8. Dyspepsia and gastro-oesophageal reflux disease | About-this-guideline | Guidance and guidelines | NICE [Internet].
[cited 2015 Aug 5]. Available from: https://www.nice.org.uk/guidance/cg184/chapter/About-this-guideline#strength-
of-recommendations
9. Dexamethasone versus betamethasone as an antenatal corticosteroid [Internet]. 2013 [cited 2015 Aug 5]. Available
from:http://www.healthynewbornnetwork.org/resource/dexamethasone-versus-betamethasone-antenatal-
corticosteroid
10. Velaphi SC, Mokhachane M, Mphahlele RM, Beckh-Arnold E, Kuwanda ML, Cooper PA. Survival of very-low-birth-
weight infants according to birth weight and gestational age in a public hospital. South Afr Med J Suid-Afr Tydskr Vir
Geneeskd. 2005 Jul;95(7):504–9.
11. Kalimba EM, Ballot DE. Survival of extremely low-birth-weight infants. South Afr J Child Health. 2013 Apr 26;7(1):
13–8.
12. Ballot DE, Chirwa TF, Cooper PA. Determinants of survival in very low birth weight neonates in a public sector
hospital in Johannesburg. BMC Pediatr. 2010;10:30.
13. Kirsten GF, Kirsten CL, Henning PA, Smith J, Holgate SL, Bekker A, et al. The outcome of ELBW infants treated with
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Guidelines for Maternal Care in South Africa:

A manual for clinics, community health centres and district
hospitals
ISBN: 978-0-620-66530-8
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GUIDELINES FOR MATERNITY CARE IN SOUTH AFRICA

A long and healthy life for all South Africans

GUIDELINES FOR MATERNITY CARE

Fourth Edition 2016

MEMBERS OF THE NATIONAL MATERNITY GUIDELINES COMMITTEE

Prof. E Buchmann Gauteng

ACRONYMS AND ABBREVIATIONS USED IN THE TEXT ................................................................................................................. 8

CHAPTER 1: MATERNITY CARE IN SOUTH AFRICA....................................................................................................................... 12

CHAPTER 15: BASIC ULTRASOUND AT DISTRICT LEVEL .......................................................................................................... 128

APPENDIX 2: ANTENATAL CORTICOSTEROID THERAPY AT DISTRICT LEVEL FOR REDUCTION OF NEONATAL

Figure 3.1 SBAR Clinical Report ..........................................................................................................................................................

Note: Figures are labeled according to the chapters not chronoligical.

ACRONYMS AND ABBREVIATIONS USED IN THE TEXT

IUD Intrauterine Death

The Maternity Guidelines for Clinics and District hospitals

The national Department of Health will support wide

The NCCEMD has recommended regular updating and

Purpose of this chapter

CHAPTER 1: MATERNITY CARE IN SOUTH AFRICA

The definition implies and includes the following :

HIV and AIDS

Health worker training

SAFE MOTHERHOOD IN SOUTH AFRICA

A NATIONAL STRATEGY FOR MATERNITY CARE

A SUPPORTIVE LEGAL FRAMEWORK

ADAPTATION TO LOCAL REALITIES

IMPROVEMENT IN THE STATUS OF WOMEN

PROVISION OF SKILLED MIDWIFERY AND OBSTETRIC SERVICES

REGIONALISED CARE AND REFERRAL SYSTEMS

CONTINUING AUDIT OF SERVICES

OBJECTIVE OF THE NATIONAL GUIDELINES

USING THESE GUIDELINES

FORMAT AND CONTENT

• neonatal care - only immediate care of the new-born is described

Purpose of this chapter

CHAPTER 2: LEVELS OF CARE

DEFINING LEVELS OF CARE

COMMUNITY HEALTH CENTRE

Requirements for a dedicated obstetric ambulance

Purpose of this chapter

PURPOSE OF RECORD KEEPING STANDARDS

• to instil good practice in record keeping

STANDARDS FOR INPATIENT RECORD KEEPING

• record keeping in all clinical areas will be subject to monitoring

ORGANISATION OF THE STANDARDS

NOTES MADE AT THE ANTENATAL CLINIC

ACUTE EVALUATION (NOT FOR ADMISSION)

ADMISSION NOTES (ACUTE ADMISSION)

Admission notes should include:

Follow-up notes (following on the admission notes) should include:

HANDOVER NOTES: TRANSFER OF ACCOUNTABILITY

INTRAPARTUM AND LABOUR WARD NOTES

REFERRAL NOTES USING THE SBAR (SITUATION-BACKGROUND-ASSESSMENT-RECOMMENDATIONS)

In the case of a telephonic consultation with a more senior colleague/referral hospital:

SURGERY AND INVASIVE PROCEDURES NOTES

• Medication names cannot be abbreviated. Spell out drug names completely.

Figure 3.1 SBAR Clinical Report

S I am calling about (name of woman) ________Ward:Hosp. No

B The woman is:-‐

Person comple8ng form: (name) _______________________RankDate_ Time_____